A nurse is caring for a patient with a tracheostomy. What should the nurse do to determine the patient needs suctioning?

A. Retractions on assessment:Retractions suggest increased respiratory effort and are a sign of respiratory distress. Their presence indicates that the airway is still obstructed or the patient is struggling to breathe, suggesting the bronchodilator has not been effective.

B. Chest tightness:Chest tightness is a subjective symptom often associated with bronchospasm or airway constriction. If it persists after bronchodilator use, it signals continued respiratory compromise and inadequate relief from the medication.

C. Use of accessory muscles:Use of accessory muscles indicates labored breathing and ongoing difficulty with ventilation. Effective bronchodilation should reduce the work of breathing and minimize reliance on these muscles.

D. SpO₂ increased from 87% to 94%:An increase in oxygen saturation indicates improved gas exchange and oxygenation, reflecting that the bronchodilator has successfully opened the airways. This is a measurable and objective sign of medication effectiveness.

A. Crackles are heard in bases. – The nurse encourages the client to cough forcefully:
Crackles are caused by fluid in the alveoli and are often not cleared with coughing. Encouraging coughing may help with mucus, but for fluid-related crackles (e.g., in heart failure), diuretics or other interventions are more appropriate.

B. Wheezes are heard in central areas. – The nurse administers an inhaled bronchodilator:Wheezes result from narrowed airways, commonly seen in asthma or bronchospasm. Bronchodilators relax airway smooth muscle, improving airflow and reducing wheezing.

C. Vesicular sounds are heard over the periphery. – The nurse has the client breathe:
Vesicular breath sounds are normal over the peripheral lung fields. No action is needed when these sounds are heard, so prompting the client to breathe differently is unnecessary.

D. Hollow sounds are heard over the trachea. – The nurse increases the oxygen flow rate:Hollow, tubular sounds (bronchial) are expected over the trachea. These are normal findings and not an indication of hypoxia. Increasing oxygen unnecessarily could be harmful.