A client with a tracheostomy has coarse breath sounds, visible secretions in the tube, and an ineffective cough. Which action should the nurse take?
1Instill normal saline into the tracheostomy before each suction pass
2Schedule suctioning every 2 hours even when no secretions are present
3Preoxygenate the client and perform suction using sterile technique✓ Correct answer
4Apply suction for 30 seconds to remove the secretions completely
Explanation
Coarse breath sounds, visible secretions, and an ineffective cough indicate a need for suctioning. Preoxygenation reduces hypoxemia risk, and sterile technique is used for open suctioning; routine saline instillation and prolonged suction are avoided.
Quick answer Preoxygenate the client and suction using sterile technique. The findings show retained airway secretions, and the procedure should limit infection and hypoxemia risk.
Why this is correct The client cannot clear visible secretions effectively. Suctioning restores airway patency, while oxygen given beforehand increases reserve during the brief interruption of ventilation and sterile open technique reduces contamination.
Easy analogy or mental picture Suctioning is like clearing a blocked straw after first making sure the person has enough air reserve. The analogy explains patency and preparation, but it does not set catheter size, pressure, duration, or monitoring requirements.
Memory hook Secretions plus ineffective cough means preoxygenate, use sterile technique, and suction briefly as needed.
NCLEX decision rule For an artificial airway, suction when assessment shows retained secretions rather than by a fixed schedule. Preoxygenate first, use sterile technique for open suctioning, and avoid routine saline instillation or prolonged suction application.
Why the other choices are wrong Routine saline instillation can cause harm without improving clearance. Fixed-schedule suctioning ignores assessment, and applying suction for 30 seconds increases hypoxemia and mucosal injury risk.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
AARC: Artificial Airway Suctioning Clinical Practice GuidelineAmerican Association for Respiratory Care