The nurse performs in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?
Discontinue suctioning and administer 100% oxygen
Discontinue suctioning and prepare for resuscitation
Continue suctioning and administer 50% oxygen
Continue suctioning and administer prescribed epinephrine
The Correct Answer is A
A. Discontinue suctioning and administer 100% oxygen: A drop in oxygen saturation and bradycardia indicates the patient is not tolerating suctioning. The priority is to stop suctioning and administer 100% oxygen to prevent hypoxia.
B. Discontinue suctioning and prepare for resuscitation: While severe cases may require resuscitation, the immediate intervention is oxygen administration, not premature resuscitation efforts.
C. Continue suctioning and administer 50% oxygen: Continuing suctioning may worsen hypoxia and bradycardia. Administering 50% oxygen may not be sufficient in a critical situation.
D. Continue suctioning and administer prescribed epinephrine: Epinephrine is used for anaphylaxis and severe cardiac issues, not for managing suction-related hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restricts the client's ability to eat, speak, or drink: Unlike a mask, a nasal cannula allows the client to eat, drink, and speak freely.
B. Delivers a low concentration of oxygen: A nasal cannula delivers a low oxygen concentration (24%-44%) at flow rates of 1-6 L/min.
C. Delivers a constant rate of a specific concentration of oxygen: Oxygen concentration varies depending on the client's breathing pattern with a nasal cannula, making it not a fixed concentration delivery system.
D. Delivers a high concentration of oxygen: High-flow oxygen delivery systems like a non-rebreather mask or Venturi mask are needed for high oxygen concentrations.
Correct Answer is D
Explanation
A. Nothing solid by mouth for 8 to 10 hours before surgery: While some surgeries may require longer fasting, the general guideline is at least 6-8 hours for solids.
B. Nothing solid by mouth for 10 to 12 hours before surgery: This is longer than necessary based on standard preoperative fasting guidelines.
C. Nothing solid by mouth for 12 to 14 hours before surgery: This is excessive and may lead to unnecessary discomfort.
D. Nothing solid by mouth for 6 to 8 hours before surgery: General guidelines recommend NPO for at least 6-8 hours before surgery to reduce the risk of aspiration during anesthesia. Clear liquids may be allowed up to 2 hours before surgery.
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