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?

Inspect the nail beds and lips for a bluish hue.

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. In clients who have dark skin, cyanosis may be difficult to detect by visual inspection of the skin alone. The nurse should inspect the nail beds and lips for a bluish hue, as these areas are more sensitive to changes in oxygen saturation.

Incorrect options:

B) Palpate the skin for warmth and moisture - This technique may help to assess for other skin conditions, such as dehydration or infection, but it does not indicate cyanosis.

C) Compare the skin color with a standardized color chart - This technique may help to assess for other skin conditions, such as jaundice or anemia, but it does not indicate cyanosis.

D) Observe the skin for pallor or ashiness - This technique may help to assess for other skin conditions, such as shock or hypovolemia, but it does not indicate cyanosis.

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