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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Coughing and deep breathing improve lung expansion but are less urgent than addressing hypoxemia (88% saturation). Oxygen administration corrects low oxygen levels immediately, making this a secondary action.

Choice B reason: Raising the head of the bed aids breathing by reducing diaphragm pressure, but it does not directly correct hypoxemia. Administering oxygen is the priority to restore saturation, making this less immediate.

Choice C reason: Administering oxygen at 2 L/min is the first action, as 88% saturation indicates hypoxemia, risking organ damage. Oxygen delivery corrects low levels, stabilizing the patient, making this the priority intervention.

Choice D reason: Administering analgesics addresses pain but does not correct hypoxemia. Pain management is secondary to ensuring adequate oxygenation, as low saturation is life-threatening, making this incorrect as the first action.

A. Spills sterile saline solution onto the sterile field B. Drops a sterile capped needle onto the sterile field C. The table remains above waist level during the procedure D. The nurse lowers a gloved hand below the waist E. The culture swab touches the drape’s 1-inch border

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: Spilling sterile saline onto the sterile field introduces potential contaminants, as the liquid may carry microbes from surrounding areas, compromising sterility. This breaks the sterile field, making it correct.

Choice B reason: Dropping a sterile capped needle onto the sterile field does not introduce contaminants, as the needle remains sterile. The field remains intact, making this an incorrect choice for a break.

Choice C reason: Keeping the table above waist level maintains sterility, as areas below the waist are considered contaminated. This is a correct practice, not a break, making it incorrect.

Choice D reason: Lowering a gloved hand below the waist exposes it to non-sterile areas, contaminating the glove. This compromises the sterile field when the hand returns, making it a correct choice.

Choice E reason: The drape’s 1-inch border is considered non-sterile. A culture swab touching it becomes contaminated, breaking the sterile field when reintroduced, making this a correct choice.

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A nurse is preparing to suction a patient with thick oral secretions. Which finding will cause the nurse to stop suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","D","E"]

Explanation

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