A nurse in an urgent care center is caring for a young adult client who requires suturing of a laceration. The client tells the nurse, "My family should have been here by now. I can't go through this without them." Which of the following responses should the nurse make?

Rationale

A. Set the suction device to 120 mm Hg: Adult nasopharyngeal suctioning requires suction pressure between 100 and 150 mm Hg to effectively remove secretions without damaging mucosal tissue. Setting the device to 120 mm Hg falls safely within this range and provides adequate negative pressure for efficient suctioning.

B. Apply suction to the catheter during insertion: Suction should never be applied during catheter insertion because it increases the risk of mucosal injury and can cause hypoxia. The catheter must be inserted gently to the appropriate depth before suctioning is activated on withdrawal. This helps protect the airway structures and maintains patient safety during the procedure.

C. Have the client tuck his chin to his chest during suctioning: The chin-to-chest position narrows the airway passage and makes catheter insertion more difficult. Nasopharyngeal suctioning requires the "sniffing" position, where the head is slightly extended to align the airway for smoother catheter passage.

D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used because they can irritate mucous membranes and pose a risk if aspirated. Water-soluble lubricants are recommended since they reduce friction, minimize trauma, and dissolve easily if small amounts enter the airway.

Rationale for Correct Choices

• Thrombophlebitis: The client has a red streak along the vein, palpable cord, warmth, tenderness, and pain at the IV site, which are classic signs of thrombophlebitis. This condition involves inflammation of the vein often accompanied by a thrombus.
• Infection: Presence of purulent drainage at the IV insertion site along with fever (38.6° C / 101.5° F) indicates a local IV-related infection. Infection can occur secondary to thrombophlebitis or as an independent complication of IV therapy.

Rationale for Incorrect Choices

• Extravasation: Extravasation involves leakage of vesicant medication into surrounding tissue causing tissue damage, which is not described here.
• Infiltration: Infiltration is the leakage of nonvesicant IV fluid into surrounding tissue, typically causing swelling, pallor, and coolness, not the red streak and purulent drainage seen in this client.
• Circulatory overload: Circulatory overload presents with dyspnea, hypertension, and edema, none of which are noted in this client.
• Phlebitis: Phlebitis involves vein inflammation and pain but does not usually include purulent drainage. Thrombophlebitis better describes the combination of inflammation with a palpable cord.