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 D

Explanation

A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.

A. Closure of mitral and aortic valves B. Closure of mitral and tricuspid valves C. Closure of pulmonic and tricuspid valves D. Closure of pulmonic and aortic valves E. Closure of aortic and tricuspid valves

Correct Answer is B

Explanation

A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.
B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.
C. The pulmonic valve closure is associated with the S2 heart sound, not S1.
D. The closure of the pulmonic and aortic valves occurs in S2, not S1.
E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.

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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?

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