The nurse is suctioning a patient's tracheostomy. Which assessment finding observed by the nurse during suctioning indicates that the procedure should be stopped immediately?

Heart rate decreases from 76 to 58 beats/min

Respiratory rate increases from 12 to 20

Blood pressure increased from 124/76 to 136/85 mmHg

Oxygen saturation decreases from 100 to 96%

Answer and Explanation

The Correct Answer is A

A. Heart rate decreases from 76 to 58 beats/min: A sudden drop in heart rate (bradycardia) during suctioning indicates vagal stimulation, which can compromise cardiac output and perfusion. Suctioning should be stopped immediately to prevent further hemodynamic instability and potential cardiac arrest.

B. Respiratory rate increases from 12 to 20: An increase in respiratory rate is a normal response to airway stimulation during suctioning. It reflects mild irritation or the body’s attempt to maintain oxygenation and does not require stopping the procedure if the patient remains stable otherwise.

C. Blood pressure increased from 124/76 to 136/85 mmHg: A slight increase in blood pressure can occur due to sympathetic stimulation during suctioning. This is typically transient and does not necessitate stopping the procedure unless the patient shows other signs of instability.

D. Oxygen saturation decreases from 100 to 96%: A minor drop in oxygen saturation during suctioning is common, especially if suctioning is brief. Oxygen supplementation and careful monitoring are appropriate, but the procedure does not need to be stopped unless desaturation is severe (<90%) or prolonged.

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

Explanation

A. Provide oral care every 12 hours: Oral care is an essential component of VAP prevention; however, every 12 hours is insufficient for mechanically ventilated patients. Evidence-based bundles recommend more frequent oral care, often every 2–4 hours, typically with chlorhexidine to reduce oropharyngeal colonization. This frequency does not meet best-practice standards.

B. Monitor ETT cuff pressure: Maintaining appropriate endotracheal tube cuff pressure (usually 20–30 cm H₂O) helps prevent microaspiration of contaminated oral and gastric secretions into the lower airway. Inadequate cuff pressure increases the risk of pathogen entry into the lungs, making regular monitoring a critical VAP prevention strategy.

C. Insert a nasogastric tube: Insertion of a nasogastric tube does not prevent VAP and may increase the risk of aspiration if not managed properly. Gastric distention and reflux can contribute to aspiration of gastric contents, thereby increasing pneumonia risk rather than reducing it.

D. Administer high doses of sedation: High sedation levels suppress cough reflexes, impair early mobilization, and prolong mechanical ventilation duration, all of which increase VAP risk. Current evidence supports daily sedation interruption and light sedation strategies rather than deep sedation.

E. Maintain head of the bed to at least 30 degrees: Elevating the head of the bed between 30–45 degrees reduces the risk of aspiration of gastric and oral secretions. This positioning decreases the likelihood of bacteria entering the lower respiratory tract and is a cornerstone of ventilator bundle protocols.

A. Remove the in-line suction system and use a sterile tracheostomy suctioning catheter B. Place the in-line suction catheter into the ET tube and suction for 10 seconds C. Disconnect the patient from the ventilator and oxygenate with the bag valve mask D. Assess the patient’s respiratory status and oxygen saturation before suctioning

Correct Answer is D

Explanation

A. Remove the in-line suction system and use a sterile tracheostomy suctioning catheter: Removing the closed in-line suction system is unnecessary and breaks sterility. The closed system is designed to allow suctioning without disconnecting the ventilator, minimizing infection risk and oxygen desaturation.

B. Place the in-line suction catheter into the ET tube and suction for 10 seconds: Suctioning before assessing the patient could cause unnecessary hypoxia, trauma, or arrhythmias. The nurse must first determine the need for suctioning based on clinical assessment and oxygenation status.

C. Disconnect the patient from the ventilator and oxygenate with the bag valve mask: Disconnecting the ventilator is not indicated when using a closed in-line suction system. The closed system allows suctioning without loss of positive pressure or oxygenation, which prevents hypoxemia.

D. Assess the patient’s respiratory status and oxygen saturation before suctioning: The first step is to evaluate the patient’s respiratory condition, including auscultation, respiratory rate, work of breathing, and SpO₂. This assessment ensures suctioning is indicated, identifies any potential complications, and allows for safe and effective removal of secretions.

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The nurse is suctioning a patient's tracheostomy. Which assessment finding observed by the nurse during suctioning indicates that the procedure should be stopped immediately?

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Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse is preparing to suction the endotracheal tube (ETT) of a patient who is on a ventilator using a closed in-line system (see image below or in attachments). What action does the nurse take first?

Correct Answer is D

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