The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped?

Heart rate increases 10 beats/min

Respiratory rate increases from 16 to 20 breaths/min

Blood pressure increases from 110/70 to 120/80 mm Hg

Heart rate decreases from 78 to 40 beats/min

Answer and Explanation

The Correct Answer is D

Rationale:

A. Heart rate increases 10 beats/min is incorrect because a mild increase in heart rate during suctioning is a common physiological response due to stimulation of the vagus nerve and stress of the procedure. An increase of 10–20 bpm is usually considered acceptable and does not necessitate stopping the procedure unless accompanied by other severe symptoms.

B. Respiratory rate increases from 16 to 20 breaths/min is incorrect because a slight increase in respiratory rate is a normal response to suctioning. The client may transiently hyperventilate to compensate for brief airway obstruction during the procedure.

C. Blood pressure increases from 110/70 to 120/80 mm Hg is incorrect because a minor rise in blood pressure is also a normal physiological response to stimulation and stress during suctioning. This change is mild and does not indicate an adverse event.

D. Heart rate decreases from 78 to 40 beats/min is correct. A sudden bradycardia during suctioning is a sign of excessive vagal stimulation and hypoxia. This is an emergency finding and indicates that the procedure should be stopped immediately. The nurse should remove the suction catheter, provide supplemental oxygen, and monitor the client for further cardiovascular compromise. Persistent bradycardia can lead to hypotension, syncope, or cardiac arrest if not addressed promptly.

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Correct Answer is C

Explanation

Rationale:
A. No action required at this time is incorrect because the ABG shows an abnormality. The pH is elevated (normal 7.35–7.45), indicating alkalosis, and the PaCO2 is low (normal 35–45 mm Hg), indicating that the alkalosis is respiratory in origin. This is uncompensated respiratory alkalosis, and interventions to address it may be needed.

B. Increase the rate and decrease tidal volume is incorrect because increasing the ventilator rate or decreasing tidal volume would further lower PaCO2, worsening respiratory alkalosis.

C. Decrease the rate and tidal volume is correct. The ABG indicates hyperventilation, which is causing the low PaCO2 and high pH. By decreasing the ventilator rate and/or tidal volume, CO2 retention will increase, helping to bring the pH back toward normal.

D. Increase the FIO2 is incorrect because the PaO2 is normal to slightly elevated (103 mm Hg on current FIO2), so supplemental oxygen is not required. The primary problem is CO2 removal, not oxygenation.

A. Excessive secretions B. Bronchospasms C. Thick secretions D. Fighting the ventilator

Correct Answer is B

Explanation

Rationale:
A. Excessive secretions is incorrect. While excessive secretions may require suctioning or hydration, they are not treated with bronchodilators. Bronchodilators relax airway smooth muscle but do not remove secretions.

B. Bronchospasms is correct. Bronchodilators, such as albuterol, are indicated for acute bronchospasm. In patients with acute respiratory failure, bronchospasm can increase airway resistance, reduce oxygenation, and make ventilation difficult. Bronchodilators relax the bronchial smooth muscle, improve airflow, and reduce work of breathing.

C. Thick secretions is incorrect. Thick or tenacious secretions require hydration, mucolytics, or suctioning, not bronchodilators, which do not affect mucus viscosity.

D. Fighting the ventilator is incorrect. Ventilator dyssynchrony may result from sedation issues, pain, anxiety, or inappropriate ventilator settings, but bronchodilators do not address the underlying cause unless bronchospasm is contributing to increased airway resistance.

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The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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