Difficulty: Medium
Average Score: 83%
Full-length
The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
Correct answer
A,C,D
Rationale
Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.