During sterile suctioning, the nurse observes the patient experiencing bronchospasm and increased intracranial pressure. What should be the nurse's immediate action?
Continue suctioning to clear the airway completely.
Adjust the pressure on the suction device.
Stop suctioning immediately and provide appropriate interventions.
Increase the suction pass time to remove more secretions.
The Correct Answer is C
Choice A rationale:
Continuing suctioning when the patient is experiencing bronchospasm and increased intracranial pressure can worsen their condition and potentially lead to further complications. It is not appropriate to continue suctioning in this situation.
Choice B rationale:
Adjusting the pressure on the suction device may not be sufficient to address the patient's current condition. Stopping suctioning and providing appropriate interventions are more crucial in this situation.
Choice C rationale:
Stopping suctioning immediately is the most appropriate action when the patient experiences bronchospasm and increased intracranial pressure. The nurse should assess the patient's airway, administer bronchodilators or other prescribed treatments as needed, and seek medical assistance if necessary.
Choice D rationale:
Increasing the suction pass time is not recommended as it can exacerbate the patient's condition and lead to complications. The focus should be on stopping suctioning and providing appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Donning personal protective equipment (PPE) is the priority action before performing sterile suctioning. This helps prevent the transmission of infection from patient to nurse and vice versa.
Choice B rationale:
Preoxygenating the patient with 100% oxygen is essential before nasopharyngeal suctioning, but the priority action is to ensure the nurse's safety by using PPE.
Choice C rationale:
Obtaining baseline data on vital signs and secretions is an important step, but it can be done after the nurse has ensured their safety with appropriate PPE.
Choice D rationale:
Inserting the catheter into the artificial airway using sterile technique is part of the procedure but should be preceded by wearing proper PPE to maintain a sterile environment.
Correct Answer is C
Explanation
"I have been coughing up blood.”.
Choice A rationale:
Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.
Choice B rationale:
A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.
Choice C rationale:
A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.
Choice D rationale:
Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.
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