A nurse is caring for a client who is unconscious after a head injury. The patient is breathing on his own but has increased oral secretions that require frequent suctioning. The nurse prepares to suction secretions from his mouth and nose. Before starting the suction process, the nurse turns on the suction machine and sets the pressure at no higher than:

 

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Correct

- 120 mmHg

- 60 mmHg

- 100 mmHg

- 200 mmHg

Rationale

When setting suction levels prior to suctioning a patient, whether it is oral, nasal, or endotracheal suctioning, the nurse should not set the suction level higher than 120 mmHg. In other words, the nurse should not suction at a pressure greater than 120 mmHg, as doing so provides too much suction and could contribute to hypoxia.

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