Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

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Get ready for the Nursing Acceleration Challenge Exam. Study with flashcards and multiple choice questions, with hints and explanations. Prepare for your exam!

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When a patient gag reflex is triggered during nasotracheal suctioning, what is the appropriate nurse response?

Apply suction while inserting the catheter.
Withdraw the catheter 2 to 3 cm.
Insert the catheter 2 to 3 cm more.
Remove the catheter.

The correct answer is: Remove the catheter.

In the context of nasotracheal suctioning, the gag reflex is a protective mechanism indicating that the airway is being irritated, which can lead to complications such as vomiting or further airway obstruction. When this reflex is triggered, the safest and most appropriate response is to remove the catheter entirely. This action prevents any potential injury to the airway or pharynx and allows the patient to regain their comfort and airway clearance without the risk of aspiration. This approach emphasizes patient safety and comfort, ensuring that the healthcare provider does not exacerbate the situation by continuing with the suctioning while the reflex is triggered. The removal of the catheter allows for a reassessment of the patient's needs and readiness for further suctioning after the reflex subsides.