Question

The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.

a) Assess the need for suctioning
b) Hyperoxygenate the client
c) Insert the suction catheter
d) Apply suction while withdrawing the catheter

Answer 1

To suction a tracheostomy, the nurse must: first assess the need for suctioning, then hyperoxygenate the client, insert the suction catheter without applying suction, and finally apply suction while withdrawing the catheter.

Step-by-step explanation:

When performing suctioning for a client with a tracheostomy tube, the nurse must follow specific steps to ensure the process is both effective and safe. The correct order of priority for these actions is as follows:

1. Assess the need for suctioning: Determine whether suctioning is necessary based on the assessment of the client's respiratory status.
2. Hyperoxygenate the client: Before inserting the catheter, provide additional oxygen to the client to prevent hypoxemia during the procedure.
3. Insert the suction catheter: Gently insert the suction catheter into the tracheostomy without applying suction.
4. Apply suction while withdrawing the catheter: Only apply suction while pulling the catheter out to minimize trauma to the airway mucosa and prevent hypoxia.