During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Administer Atropine.

Call the health care provider immediately.

Continue to clear the airway.

Stop suctioning the patient.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering Atropine can increase the heart rate, but it is not the immediate first action. The priority is to stop the stimulus causing the vagal response, which in this case is the suctioning.

Choice B reason:

Calling the healthcare provider is important, but the immediate action should be to stop the suctioning to eliminate the cause of the vagal response. Once the immediate issue is addressed, notifying the provider can follow.

Choice C reason:

Continuing to clear the airway can exacerbate the vagal response and worsen the patient's condition. The immediate action should be to stop the suctioning.

Choice D reason:

Stopping the suctioning is the best immediate action to take when the patient becomes diaphoretic, nauseous, and experiences a significant drop in heart rate. This response is likely due to vagal stimulation, and stopping the suctioning will help alleviate the symptoms.

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Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

A. Elevate the client's head on two pillows B. Decrease the noise level in the client's room C. Suction the endotracheal tube frequently D. Administer a stool softener E. Give a 500cc NS fluid bolus

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

Explanation

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

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During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

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

Explanation

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