You are an RN who is precepting a newly graduated nurse. The new grad asks you what the signs and symptoms are for a patient with Cushing's Triad.
Which of the following WOULD NOT be part of your answer?

Choice A rationale

Placing an NG tube could potentially worsen a basilar skull fracture or cause further injury by penetrating the cranial vault if the cribriform plate is compromised. This intervention is contraindicated when clear fluid, possibly cerebrospinal fluid, is draining from the nose, indicating a potential breach in the dura mater.

Choice B rationale

Testing the clear fluid for the presence of glucose is a critical diagnostic step. Cerebrospinal fluid (CSF) contains glucose, whereas nasal secretions do not. A positive glucose test strongly indicates a CSF leak, which is a significant complication of facial trauma that requires specific management to prevent intracranial infection. Normal CSF glucose ranges from 40 to 70 mg/dL.

Choice C rationale

Encouraging coughing and deep breathing would increase intrathoracic and intracranial pressure, which could exacerbate a CSF leak and potentially introduce pathogens into the intracranial space. This action should be avoided as it poses a risk for further neurological complications such as meningitis.

Choice D rationale

Placing a mustache dressing on the patient might absorb the drainage but does not address the underlying issue of a potential CSF leak. Furthermore, applying pressure or occluding the nares could impede the free flow of CSF, potentially leading to a build-up of pressure and increasing the risk of retrograde infection into the central nervous system.

Choice A rationale

Suctioning should be performed only when clinically indicated, such as in the presence of visible secretions, adventitious breath sounds, or a decline in oxygen saturation. Routine, unnecessary suctioning can cause mucosal trauma, hypoxemia, and increased risk of infection. This "as needed" approach minimizes potential complications and preserves airway integrity.

Choice B rationale

Hyperoxygenating the patient with 100% oxygen for 30-60 seconds prior to suctioning helps to create an oxygen reserve in the lungs and minimize the risk of hypoxemia during the procedure. Suctioning can transiently reduce lung volumes and gas exchange, and pre-oxygenation mitigates this by saturating hemoglobin and dissolved plasma oxygen.

Choice C rationale

Suctioning for longer than 10-15 seconds on each pass significantly increases the risk of hypoxemia, atelectasis, and vagal stimulation leading to bradycardia. Prolonged suctioning depletes oxygen from the airways and can cause physiological distress. Brief passes allow for reoxygenation between attempts and minimize adverse events.

Choice D rationale

Performing hand hygiene prior to suctioning is a critical infection control measure. This practice reduces the transmission of microorganisms from the healthcare provider's hands to the patient's airway, thereby preventing healthcare-associated infections like ventilator-associated pneumonia. Adherence to strict aseptic technique is paramount in airway management.

Choice E rationale

Suctioning should never be performed while inserting the catheter into the artificial airway. Applying negative pressure during insertion can cause significant mucosal trauma, bleeding, and increased risk of infection by pulling tissue into the catheter lumen. Suction should only be applied intermittently and during withdrawal of the catheter, to remove secretions effectively and safely.