Saunders Respiratory Practice

How can a nurse determine if a client tolerates nasotracheal suctioning?

1. Coughing occurs with suctioning.

2. The client remains calm and still.

3. There is no bleeding after the procedure.

4. The client reports decreased pain.

The correct answer is: Coughing occurs with suctioning.

Coughing during nasotracheal suctioning can be an important indicator of how well a client is tolerating the procedure. Coughing may reflect the body's natural response to clear irritants or secretions from the airway, suggesting that the suctioning is effectively stimulating the airway to remove obstructive material. While the other factors might be relevant to overall patient comfort and safety, they do not specifically indicate tolerance of the suctioning procedure itself. For instance, a calm and still client (remaining calm and still) might not necessarily mean they are tolerating the suctioning; they might just be anxious or subdued. The absence of bleeding (no bleeding after the procedure) is a sign of procedural safety but does not directly reflect tolerance. Similarly, a report of decreased pain (client reports decreased pain) is important for assessing comfort levels but does not specifically indicate that the client is tolerating the suctioning process effectively. Thus, coughing serves as a direct physiological response that indicates the client is reacting to the suctioning, showing a level of tolerance to the procedure.