A nurse has completed sterile suctioning for a patient. What should be the nurse's next action after suctioning?

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

Choice A rationale:

The nurse should not insert the catheter until resistance is met during nasopharyngeal suctioning. This action could cause trauma to the nasal mucosa or other structures in the nasopharynx.

Choice B rationale:

Preoxygenating the patient with 100% oxygen is important before nasopharyngeal suctioning to prevent hypoxia during the procedure. Suctioning can temporarily decrease oxygen levels, so preoxygenation helps maintain adequate oxygenation.

Choice C rationale:

Applying intermittent suction while inserting the catheter is not recommended during nasopharyngeal suctioning. Continuous suction is preferred for effective removal of secretions.

Choice D rationale:

Limiting each suction pass to no more than 15 seconds is an essential practice during nasopharyngeal suctioning. Prolonged suctioning can cause hypoxia and discomfort for the patient.

Choice E rationale:

Rinsing the catheter and tubing with saline after each suction pass helps maintain patency and prevent the accumulation of secretions, ensuring effective suctioning during the procedure.