Which client assessment should the nurse perform during nasopharyngeal suctioning?
A.
Auscultate the bowel sounds in all four quadrants.
B.
Palpate the client’s pedal pulse volume bilaterally.
C.
Determine the elasticity of the client’s skin turgor.
D.
Observe the client’s skin and mucous membranes.
The correct answer and Explanation is :
The correct answer is D. Observe the client’s skin and mucous membranes.
During nasopharyngeal suctioning, a nurse should closely monitor the client for any signs of hypoxia or distress. Observing the client’s skin and mucous membranes is a crucial part of this assessment because these areas provide direct indicators of oxygenation status.
Hypoxia, or insufficient oxygen levels, can lead to cyanosis, which is a bluish discoloration of the skin, particularly around the lips, fingertips, and mucous membranes. Cyanosis signals inadequate oxygen delivery to tissues and can be an early sign of respiratory distress or failure during suctioning. By closely observing the skin and mucous membranes, the nurse can quickly identify changes in the client’s oxygen status and intervene as necessary.
Additionally, suctioning can stimulate the vagus nerve, leading to bradycardia (a drop in heart rate) and, in some cases, can cause fainting or decreased cardiac output. These changes might be reflected by pallor or mottling of the skin. Proper oxygenation is critical during and after the procedure, and observing these physical signs allows the nurse to assess whether suctioning is causing or exacerbating respiratory compromise.
On the other hand, options A (auscultating bowel sounds), B (palpating pedal pulses), and C (assessing skin turgor) are not directly relevant to the procedure of nasopharyngeal suctioning. These assessments pertain to other systems and conditions, such as gastrointestinal motility, peripheral circulation, and hydration status, none of which would be immediately affected or assessed during this specific respiratory intervention.
In summary, observing the client’s skin and mucous membranes ensures the nurse can quickly detect signs of hypoxia or other complications that might arise during nasopharyngeal suctioning, facilitating prompt intervention to maintain airway patency and adequate oxygenation.