A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Obtain a cardiology consult.

Perform pre-oxygenation prior to suctioning.

Suction the client less frequently.

Administer an antidysrhythmic medication.

Answer and Explanation

The Correct Answer is B

B. This is advised to prevent hypoxemia, which can manifest as tachycardia and arrhythmia, conditions indicated by an increased and irregular heart rate. Pre-oxygenation helps maintain adequate oxygen levels in the blood, which can be compromised during the suctioning process.

A. Obtaining a cardiology consult might be necessary if the client's heart rate increases and becomes irregular. However, it's not the immediate action the nurse should take. This option is more appropriate for addressing the underlying cause of the client's dysrhythmia rather than the immediate management during suctioning.

C. Suctioning the client less frequently might be appropriate if the client's response to suctioning is causing distress or physiological changes like increased heart rate. However, if suctioning is necessary due to secretions in the airway, simply reducing the frequency might not be sufficient to address the client's cardiovascular response.

D. Administering an antidysrhythmic medication should be considered if the client's heart rate increases and becomes irregular during or after suctioning, especially if the dysrhythmia persists or worsens.

However, this should be done under the guidance of a healthcare provider and after assessing the client's overall condition, including potential causes of the dysrhythmia.

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Correct Answer is A

Explanation

A. Dobutamine is a positive inotropic agent that increases myocardial contractility, leading to improved cardiac output. Enhanced cardiac output can result in improved renal perfusion and increased urine output, which is a positive indicator of improved cardiac function in clients with heart failure.

B. Decreased blood glucose level is not typically associated with the effectiveness of dobutamine. Dobutamine primarily affects cardiac contractility and does not directly influence blood glucose levels.

C. Decreased blood pressure would not typically indicate the effectiveness of dobutamine. While dobutamine can increase cardiac output, it does not necessarily lead to a decrease in blood pressure.

D. Increased heart rate may occur as a compensatory mechanism in response to increased cardiac output due to dobutamine administration. However, increased heart rate alone may not reliably indicate the effectiveness of dobutamine.

A. The patient's blood pressure is 164/98. B. The patient appears somnolent. C. The patient's oxygen saturation is 90%. D. The patient reports feeling weak.

Correct Answer is B

Explanation

B Somnolence, or excessive sleepiness, can indicate respiratory depression, hypercapnia (elevated PaCO2), or impending respiratory failure. Somnolence in this context is concerning as it may suggest worsening respiratory status and impending respiratory compromise. Therefore, it should be immediately reported to the healthcare provider for further evaluation and intervention.

A blood pressure of 164/98 mmHg is elevated but may not necessarily require immediate intervention, especially if the patient is not exhibiting signs of acute hypertensive crisis or end-organ damage.

However, it should be closely monitored and managed as appropriate. While hypertension may contribute to respiratory distress, it may not be the most critical finding to report immediately in a patient with possible respiratory failure and a high PaCO2.

C An oxygen saturation of 90% indicates hypoxemia, which can exacerbate respiratory failure and contribute to respiratory distress. While hypoxemia requires prompt intervention to improve oxygenation, it may not be the most critical finding to report immediately if the patient is not showing signs of severe respiratory distress or impending respiratory failure. However, it should be closely monitored and managed to prevent further deterioration.

D Weakness is a nonspecific symptom and may be related to various underlying causes, including respiratory failure, electrolyte imbalances, or systemic illness. While weakness warrants further assessment and management, it may not be the most urgent finding to report immediately in a patient with possible respiratory failure and a high PaCO2 unless it is accompanied by other concerning symptoms or signs of impending respiratory compromise.

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A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

Correct Answer is A

Explanation

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

Correct Answer is B

Explanation

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