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 C

Explanation

A. The closure of the pulmonic and mitral valves corresponds to heart sound S1, not S2.
B. The tricuspid and mitral valves close with S1.
C. Heart sound S2 represents the closure of the aortic and pulmonic valves, signaling the end of systole and the beginning of diastole.
D. The mitral valve closes with S1, not S2.
E. The pulmonic and tricuspid valves do not correspond with S2.

A. "I would palpate, inspect, percuss, and the auscultate.” B. "I would percuss, palpate, auscultate, and then inspect.” C. "I would auscultate, inspect, percuss, and then palpate." D. "I would inspect, auscultate, palpate, and then percuss." E. "I would inspect, palpate, percuss, then auscultate.”

Correct Answer is E

Explanation

A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.

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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

The nurse is asked to describe what the heart sound S2 represents. What would be the correct response by the nurse?

Correct Answer is C

Explanation

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

Correct Answer is E

Explanation

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