A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Pulse 60

Pulse 90

Oxygen saturation of 92%

Oxygen saturation 89%

Blood pressure 130/80

Answer and Explanation

The Correct Answer is D

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

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Correct Answer is A,E,D,F,C,B

Explanation

Unoxygenated blood flows from the body into the right atrium, then passes through the pulmonary artery to the lungs. After receiving oxygen in the lungs, blood flows back to the heart via the pulmonary vein into the left atrium. It then moves into the left ventricle and is finally pumped out to the body through the aorta.

A. Enlargement of the heart ventricle B. Turbulent blood flow C. Persistently slow heart beat D. Extreme pulse deficit E. Coronary artery blockage

Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

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A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A,E,D,F,C,B

Explanation

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

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