A nurse is preparing to suction a patient with thick oral secretions. Which finding will cause the nurse to stop suctioning?
Oxygen saturation 88%
Blood pressure 132/88 mmHg
Heart rate 110 bpm
Respiratory rate 24 breaths/min
The Correct Answer is A
Choice A reason: An oxygen saturation of 88% indicates hypoxemia, a critical finding requiring the nurse to stop suctioning. Suctioning can worsen hypoxia by removing oxygen from the airway, necessitating immediate cessation and oxygenation to stabilize the patient, making this the priority reason to halt the procedure.
Choice B reason: Blood pressure of 132/88 mmHg is within normal range and not a reason to stop suctioning. Suctioning may cause transient vital sign changes, but this stable reading does not indicate distress, making it an inappropriate reason to halt the procedure.
Choice C reason: A heart rate of 110 bpm indicates tachycardia, possibly from suctioning stress, but is not critical enough to stop unless accompanied by other signs (e.g., hypoxia). Oxygen saturation of 88% poses a greater immediate risk, making this less urgent.
Choice D reason: A respiratory rate of 24 breaths/min is elevated but within acceptable limits during suctioning, which can stimulate breathing. Hypoxemia (88% saturation) is a more immediate threat, requiring suctioning to stop, making this finding less critical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Transfusing over 6 hours is too long; packed red blood cells should infuse within 2–4 hours to prevent bacterial growth. This is incorrect for safe administration.
Choice B reason: Verifying the client’s identity with another nurse ensures the correct patient receives the transfusion, preventing errors. This is a standard safety protocol, making it the correct action.
Choice C reason: A 24-gauge IV catheter is too small, risking hemolysis. Larger gauges (18–20) are required for blood, making this incorrect for transfusion administration.
Choice D reason: Priming with D5W causes hemolysis, as glucose solutions damage red cells. Normal saline is used, making this incorrect and unsafe for transfusion.
Correct Answer is C
Explanation
Choice A reason: Urgent procedures are needed soon (e.g., within hours), like appendicitis, but not immediately. Hemorrhaging requires instant action to prevent life-threatening blood loss, making this classification less appropriate than emergency.
Choice B reason: Major refers to procedure complexity, not timing. Hemorrhaging demands immediate intervention regardless of complexity, as bleeding threatens life, making major an incorrect classification for the procedure’s urgency.
Choice C reason: Emergency procedures are required immediately to save life, as with active hemorrhaging. Rapid blood loss risks hypovolemic shock, necessitating urgent surgical return, correctly classifying this as an emergency procedure.
Choice D reason: Elective procedures are planned and non-urgent, like cosmetic surgery. Hemorrhaging is life-threatening, requiring immediate intervention, not a scheduled event, making elective an incorrect classification.
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