A nurse is performing oropharyngeal suctioning on a client. Which action would the nurse include?

Use clean technique.

Apply suction as the catheter is introduced.

Flush the catheter with saline between catheter insertions.

Limit suctioning to 25- to 30-second intervals at one time.

Answer and Explanation

The Correct Answer is C

Oropharyngeal suctioning is the mechanical removal of secretions from the posterior pharynx to maintain airway patency and prevent aspiration. The procedure is indicated when a patient is unable to clear oral debris through coughing or swallowing, which can lead to stertorous respirations or respiratory distress. Maintaining catheter patency is essential during the procedure to ensure the vacuum pressure remains effective for the removal of thick or tenacious mucus.

Rationale for correct answer

3. The nurse must rinse the catheter with sterile water or normal saline between passes to clear the lumen of accumulated secretions. This ensures that subsequent suctioning attempts are not hindered by clogged tubing and maintains a clean interface for the procedure. It is a fundamental step in catheter maintenance.

Rationale for incorrect answers

1. While oropharyngeal suctioning is not strictly a sterile procedure like endotracheal suctioning, modern hospital protocols generally require sterile technique to prevent the introduction of pathogens. Using only clean technique (non-sterile gloves) is often considered inadequate in an acute care setting where the risk of cross-contamination is high. Standard practice prioritizes aseptic precautions.

2. Suction should never be applied during the insertion of the catheter, as this can cause unnecessary trauma to the oral mucosa and deplete the patient's oxygen. The nurse must only engage the suction port while withdrawing the catheter. This follows universal safety principles for all suctioning procedures.

4. Suctioning for 25 to 30 seconds is excessively long and can lead to severe hypoxemia and vagal stimulation. The maximum duration for a single suction pass should be limited to 10 to 15 seconds to allow for adequate recovery and oxygenation. Prolonged intervals increase the risk of cardiac arrhythmias.

Test-taking strategy

Prioritize safety timing: Remember the 10 to 15 second rule for all suctioning. Option 4 (25-30 seconds) is a dangerous distractor that could cause harm.
Evaluate procedure flow:
- Rule out 2 because suction on insertion is always incorrect.
- Rule out 1 because sterile is a higher standard of care than clean in the airway, and NCLEX-style questions usually favor the highest safety standard.
Identify maintenance needs: Think about the physical reality of the task; if you suck up thick mucus, the tube will get blocked. Option 3 is the logical solution to maintain the tool's function.
Match technique to anatomy: Oropharyngeal involves the mouth and throat; flushing between passes keeps the path clear for effective pulmonary hygiene.

Take home points

Oropharyngeal suctioning should be performed only when clinically indicated by the presence of visible or audible secretions.
The nurse should encourage the patient to cough and deep breathe between suctioning passes to facilitate oxygenation.

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Correct Answer is ["A","B","E"]

Explanation

Suctioning is a high-risk intervention used to maintain patency in patients with artificial airways who cannot clear secretions independently. Because the procedure can cause hypoxia and mucosal trauma, it should never be performed as a routine or scheduled task. Clinical decisions to suction must be based on a thorough assessment of the patient's respiratory status, including physical signs of obstruction and changes in physiological monitoring.

Rationale for correct answers

1. The presence of visible secretions within the endotracheal or tracheostomy tube is a direct indication that the airway is obstructed. These secretions increase airway resistance and must be removed to ensure adequate tidal volumes and oxygenation. It is one of the most objective signs that suctioning is required.

2. A sawtooth pattern on the capnography (EtCO2) waveform is a specific monitor finding that indicates turbulent airflow caused by secretions in the circuit or airway. This visual indicator allows the nurse to identify the need for suctioning even before audible adventitious sounds are heard. It is a highly sensitive clinical marker.

5. Excessive, unproductive coughing often indicates that secretions are irritating the carina or obstructing the airway lumen, but the patient is unable to move them. Suctioning provides the mechanical assistance needed to clear these irritants and restore comfortable ventilation. It helps prevent patient exhaustion.

Rationale for incorrect answers

3. Clear breath sounds indicate that the lower airways are patent and free of obstructive secretions. Suctioning a patient with clear sounds is unnecessary and exposes the patient to the risks of mucosal trauma and hypoxia without clinical benefit. Assessment findings must justify the intervention.

4. Suctioning should be performed on a PRN (as needed) basis rather than a fixed schedule like “every 3 hours.” Scheduled suctioning increases the frequency of iatrogenic injury to the trachea and increases the risk of introducing pathogens. The nurse should assess frequently but only suction when indications are present.

Test-taking strategy

Identify PRN vs. scheduled: Always rule out scheduled suctioning (Option 4). The correct approach is always based on assessment.
Evaluate clinical signs:
- Clear breath sounds (Option 3) means do nothing.
- Visible secretions (Option 1) and coughing (Option 5) are red flags for obstruction.
Identify advanced monitoring: Recognize that modern monitors provide clues; a sawtooth on EtCO2 (Option 2) is the textbook waveform for secretions.
Select for necessity: In SATAs only choose the options that represent a deficit or an abnormal finding that requires intervention.

Take home points

Indications for suctioning include increased peak inspiratory pressure, decreased oxygen saturation, and audible crackles over the trachea.
Routine saline instillation before suctioning is no longer recommended as it may push bacteria deeper into the lungs.

A. Apply suction. B. Assist patient to semi-Fowler’s or high Fowler’s position, if able. C. Advance catheter through nares and into trachea. D. Have client take deep breaths. E. Lubricate catheter with water-soluble lubricant. F. Apply sterile gloves. G. Perform hand hygiene. H. Withdraw catheter

Correct Answer is G,B,F,D,E,C,A,H

Explanation

1. Perform hand hygiene (Step 7)
Hand hygiene reduces the risk of introducing pathogens into the airway and prevents cross-contamination. It is always the first step before any invasive procedure.
2. Assist client to semi-Fowler’s or high Fowler’s position, if able (Step 2)
Upright positioning promotes lung expansion, improves oxygenation, and makes insertion of the catheter easier by aligning the airway.
3. Apply sterile gloves (Step 6)
Sterile gloves maintain asepsis during suctioning, which is a sterile procedure. This protects both the patient and nurse from infection.
4. Have client take deep breaths (Step 4)
Deep breathing increases oxygen reserves and reduces the risk of hypoxia during suctioning, since suctioning temporarily interrupts airflow.
5. Lubricate catheter with water-soluble lubricant (Step 5)
Lubrication minimizes trauma to the nasal mucosa and facilitates smooth passage of the catheter through the nares.
6. Advance catheter through nares and into trachea (Step 3)
The catheter is gently inserted until resistance or coughing indicates entry into the trachea. This ensures secretions are accessed at the source.
7. Apply suction (Step 1)
Suction is applied while withdrawing the catheter, not during insertion, to avoid mucosal damage and hypoxia. Suction removes secretions effectively.
8. Withdraw catheter (Step 8)
The catheter is withdrawn while rotating to maximize secretion removal. This completes the suctioning cycle safely.

Test-taking strategy

Standardize the start: Nearly every nursing procedure begins with hand hygiene (7).
Prioritize preparation: You must position the patient (2) and prepare the sterile field/gloves (6) before touching the patient or equipment.
Avoid trauma: Always lubricate (5) before you insert (3).
Apply the safety rule: You must hyperoxygenate (4) before you suction, and you must never apply suction (1) while pushing the tube in; it only happens during withdrawal (8).

Take home points

Water-soluble lubricant is mandatory to prevent lipid pneumonia and facilitate smooth passage through the nares.
Semi-Fowler's or high Fowler's position helps the patient hyperventilate and facilitates the anatomical passage of the catheter.

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A nurse is performing oropharyngeal suctioning on a client. Which action would the nurse include?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with an artificial airway. Which of the following are reasons to suction the client? Select all that apply

Correct Answer is ["A","B","E"]

Explanation

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Correct Answer is G,B,F,D,E,C,A,H

Explanation

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