Evolve HESI Practice Exam

Which nursing action is crucial after performing a nasotracheal suctioning procedure?

1. Assess vital signs

2. Keep the client in a supine position

3. Monitor oxygen saturation

4. Document the amount of secretions

The correct answer is: Monitor oxygen saturation

After performing a nasotracheal suctioning procedure, monitoring oxygen saturation is crucial because suctioning can temporarily disrupt the airway and lead to hypoxia. During the procedure, the patient is at risk for decreased oxygen levels due to the removal of secretions, which may also cause transient airway irritation. By assessing oxygen saturation levels, the nurse can determine if the suctioning has impacted the patient's respiratory status and respond appropriately to any changes. Monitoring oxygen saturation allows for the timely identification of potential complications related to low oxygen levels, enabling prompt interventions to maintain adequate oxygenation. This is especially important in patients with pre-existing respiratory issues or those who are critically ill, as they may have a lower tolerance for oxygen deprivation. In contrast, while assessing vital signs is important in overall patient care, it is not as immediately relevant in the context of monitoring after suctioning as oxygen saturation levels. Keeping the client in a supine position is not typically recommended immediately after suctioning, as positioning can impact respiratory function, and a more upright position may be beneficial. Documenting the amount of secretions is also important for record-keeping but does not directly affect the immediate care and safety of the patient following the suctioning procedure.