Practice Question
Indications to stop suctioning a tracheostomy and oxygenate include:
Answer Choices:
Correct Answer:
Coughing
Rationale:
🔷 Coughing
🔷 Forceful or persistent coughing during suctioning indicates that the catheter is irritating the airway or going too deep.
🔷 This can trigger bronchospasm or worsen respiratory distress if suctioning continues.
🔷 Coughing also increases intrathoracic pressure, which may transiently reduce venous return and worsen hemodynamics.
🔷 At this point, the nurse should stop suctioning, provide reassurance and supplemental oxygen, and allow the client to recover.
🔷 Sudden respiratory distress
🔷 If the client suddenly becomes tachypneic, dyspneic, or anxious, suctioning is no longer therapeutic but harmful.
🔷 This may mean too much airway obstruction, mucus shifting, or hypoxia caused by prolonged suctioning.
🔷 Respiratory distress is a red flag that the client’s gas exchange is compromised, and oxygen must be prioritized over continued suction.
🔷 SpO₂ dropping
🔷 Suctioning temporarily removes oxygen along with secretions, and a drop in SpO₂ is a direct sign of worsening hypoxemia.
🔷 If saturation begins to fall (e.g., from 96% to 90% or lower), the nurse must stop suctioning immediately and administer oxygen.
🔷 Prolonged hypoxia can cause cardiac irritability, cerebral hypoxia, and organ damage, so this is a critical threshold.
🔷 Cardiac dysrhythmias
🔷 Dysrhythmias may appear because hypoxemia and vagal stimulation from suctioning alter cardiac conduction.
🔷 Premature beats, tachyarrhythmias, or other rhythm changes are serious warning signs that the suctioning is not well tolerated.
🔷 The priority is to stop suction, provide oxygen, check vital signs, and notify the provider if the arrhythmia persists.
🔷 New-onset bradycardia
🔷 Suctioning stimulates the vagus nerve, which can sharply decrease heart rate and even cause asystole if continued.
🔷 New bradycardia (especially in a previously stable client) is a classic sign of vagal overstimulation and severe hypoxia.
🔷 The nurse must stop suctioning immediately, provide 100% oxygen, assess pulse, and be ready for emergency intervention.
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This question is from NURSING CONCEPTS II- MIDTERM EXAM FALL 2025 which contains 98 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Concept-Based Assessment Level Exam(s)
- Answer Choices: 5