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 ["C","D","E","F"]

Explanation

A. Administering antibiotics helps target the suspected infection and prevent its spread. Broad-spectrum antibiotics are typically initiated until the specific pathogen is identified through cultures. This action should be completed as soon as possible within the first hour.

D. Lactate measurement is important in assessing tissue perfusion and the severity of sepsis. Elevated lactate levels indicate tissue hypoperfusion and can help identify patients at higher risk of mortality. Monitoring lactate levels guides resuscitation efforts and helps in assessing the response to treatment.

E. Fluid resuscitation is a cornerstone in the management of sepsis. Administering a large volume of intravenous fluids helps restore intravascular volume, improve tissue perfusion, and prevent further organ dysfunction. The recommended initial fluid bolus is 30 ml/kg of crystalloid solution, such as normal saline, administered rapidly within the first few hours of recognition of sepsis.

F. Blood cultures help identify the causative organism(s) responsible for the sepsis. This information is crucial for guiding antibiotic therapy, especially in cases of severe sepsis or septic shock. Blood cultures should be obtained before initiating antibiotic therapy to maximize their sensitivity and specificity.

B. Type and cross-match for packed red blood cells (PRBCs) are indicated in situations where blood transfusion may be required, such as severe anemia or active bleeding. While sepsis can lead to various complications, such as disseminated intravascular coagulation (DIC), the priority in the first hour is resuscitation and antibiotic administration.

G. Obtaining a urine specimen may be indicated to assess for urinary tract infection (UTI), which can be a potential source of sepsis. However, in the initial management of sepsis, obtaining blood cultures (option F) takes precedence as blood cultures provide more critical information for guiding antibiotic therapy.

H. Obtaining a wound culture may help identify the specific pathogens present in the wound and guide antibiotic therapy if the wound is suspected to be the source of sepsis. However, in the first hour of managing sepsis, the priority is to initiate broad-spectrum antibiotics and obtain blood cultures, as these interventions are more urgent in preventing further complications from sepsis.

A. The rapid response team will begin with defibrillation and then progress to cardiopulmonary resuscitation if needed B. It would be best if you waited outside, as you won't want to see cardiopulmonary resuscitation performed on your loved one C. As long as the team is doing cardiopulmonary resuscitation, your loved on has a normal blood flow throughout their body D. The rapid response team cannot defibrillate your loved on because they are in systole; they are continuing cardiopulmonary resuscitation.

Correct Answer is D

Explanation

D. Asystole represents the absence of electrical activity in the heart and is not amenable to defibrillation. Therefore, the RRT would continue cardiopulmonary resuscitation (CPR) with chest compressions and may administer medications or other interventions as indicated. This statement provides accurate information to the family about the patient's condition and the actions being taken by the RRT.

A. Defibrillation is not indicated for asystole. Asystole represents a flatline on the cardiac monitor, indicating the absence of electrical activity in the heart. Defibrillation is only effective for certain types of cardiac rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia. Therefore, the RRT would not use defibrillation for a patient in asystole.

B. It does not provide the family with information about the patient's condition or the actions being taken by the RRT. Moreover, excluding the family from the patient's care may cause additional distress and prevent them from being present to support their loved one during a critical situation.

C. Cardiopulmonary resuscitation (CPR) is performed to maintain blood flow and oxygenation to vital organs during cardiac arrest. However, it does not restore normal blood flow or circulation. The goal of CPR is to provide temporary support until advanced interventions can be initiated or until return of spontaneous circulation (ROSC) is achieved.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED) Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["C","D","E","F"]

Explanation

The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?

Correct Answer is D

Explanation

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