(Select all that apply): A nurse is preparing to perform nasopharyngeal suctioning for a patient with a nasopharyngeal tube (NPT). What actions should the nurse take during the procedure? Select all that apply.

"I have been coughing up blood.”.

Choice A rationale:

Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.

Choice B rationale:

A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.

Choice C rationale:

A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.

Choice D rationale:

Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.

Choice A rationale:

The nurse should limit each suction pass to no more than 10 seconds to minimize the risk of tissue damage and hypoxia. Prolonged suctioning can cause trauma to the mucosa and lead to inadequate oxygenation.

Choice B rationale:

The nurse should apply suction while inserting the catheter to prevent the catheter from touching the airway walls before suction is initiated. This helps avoid stimulating the gag reflex and causing discomfort to the client.

Choice C rationale:

Rotating the catheter between the thumb and forefinger helps to facilitate even suctioning and prevent the catheter from adhering to the airway walls. It allows for effective removal of secretions without causing harm to the delicate tissues.

Choice D rationale:

After each suction pass, the nurse should rinse the catheter and tubing with saline to maintain its patency and prevent the buildup of secretions. This practice ensures that subsequent suctions are effective in clearing the airway.

Choice E rationale:

Suctioning more than three times in a row is not recommended because it can lead to hypoxia and tissue trauma. Frequent suctioning can reduce the oxygen levels in the airway and cause damage to the delicate tissues.