A nurse is caring for a client who has a tracheostomy tube and requires suctioning.

Which of the following actions should the nurse take to prevent hypoxia during the procedure?

All of the above

Rationale: The nurse should apply suction for no longer than 10 seconds at a time, preoxygenate the client with 100% oxygen before suctioning, and limit the number of suction passes to three per session to prevent hypoxia during tracheostomy suctioning. These actions help to minimize the interruption of oxygen delivery and reduce the risk of mucosal trauma and bleeding.

Incorrect options:

None

Respiratory depression

Rationale: Respiratory depression is a life-threatening complication of substance abuse, especially opioid overdose, that requires immediate intervention. The nurse should report this finding to the provider and prepare to administer naloxone, an opioid antagonist, as prescribed.

Incorrect options:

A) Dilated pupils - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.

B) Slurred speech - This is a common finding in clients who abuse depressants, such as alcohol or benzodiazepines, but it is not an emergency.

C) Agitation and restlessness - This is a common finding in clients who abuse stimulants, such as cocaine or methamphetamine, but it is not an emergency.