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 A

Explanation

Choice A reason:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B reason:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C reason:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D reason:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

A. Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain. B. Lorazepam 2 mg IV now for the client experiencing restlessness and picking at tubing. C. Morphine sulfate 4 mg IV now for the client experiencing incisional pain. D. One unit packed red blood cells STAT for the client with hemoglobin of 9.5 g/dL.

Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

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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

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

Correct Answer is A

Explanation

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

Correct Answer is A

Explanation

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

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