Saunders Respiratory Practice

What action should the nurse take if a mechanically ventilated client becomes restless and tachycardic during endotracheal suctioning?

1. Continue suctioning while monitoring vital signs

2. Notify the registered nurse

3. Increase the suction pressure

4. Change the client's position immediately

The correct answer is: Notify the registered nurse

In the scenario where a mechanically ventilated client becomes restless and tachycardic during endotracheal suctioning, notifying the registered nurse is appropriate because it ensures that a more experienced clinician can assess and manage the situation. Restlessness and tachycardia could indicate hypoxia, anxiety, or a response to inadequate ventilation, all of which require a careful evaluation and potentially a change in the patient’s care plan. By involving the registered nurse, you can ensure a collaborative approach to patient care, allowing for the necessary interventions to be instituted. This could include adjusting sedation levels, ensuring proper ventilation settings, or assessing for complications from suctioning itself. Other actions such as continuing suctioning or increasing suction pressure may exacerbate the client's distress or cause further complications, while changing the client's position might not be immediately relevant to the distress observed and could take time that the patient may not afford given their current state. Therefore, reaching out for assistance aligns with best practices in ensuring patient safety and quality care.