Author Question: While performing nasotracheal suctioning, the nurse notes the older adult client is moving the head ... (Read 109 times)

ap345 · **on:** Jun 25, 2018

While performing nasotracheal suctioning, the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate?

Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Hyperinflate the client's lungs
D) Apply restraints to the client's arms and legs
E) Hyperoxygenate the client

Question 2

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82. Which nursing diagnosis is a priority for this client?

A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output

gcook · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A, C, E

The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.

Answer to Question 2

Answer: B

A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82 is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.