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. Polyuria: COPD with chronic respiratory acidosis is not associated with excessive urine production. Instead, clients may experience fluid retention due to right-sided heart failure (cor pulmonale).
B. Delirium: Chronic respiratory acidosis leads to CO₂ retention, which can cause confusion, drowsiness, and even delirium due to cerebral vasodilation and altered mental status.
C. Osteoporosis: While COPD patients may have osteoporosis due to steroid use or inactivity, it is not a direct effect of chronic respiratory acidosis.
D. Anxiety and depression: While common in COPD due to lifestyle limitations, anxiety and depression are not direct physiological effects of respiratory acidosis.
Correct Answer is C
Explanation
A. Temperature: While temperature monitoring is important, hypothermia is not the most immediate concern after general anesthesia.
B. Heart rate: Although heart rate should be monitored, it is not the first priority in assessing an anesthetized patient.
C. Respirations: Airway and breathing are the top priorities in the PACU. General anesthesia can depress respiratory function, increasing the risk of airway obstruction or hypoventilation. Ensuring adequate ventilation is the first step in assessment.
D. Blood pressure: Blood pressure is important but secondary to airway and breathing in the initial assessment.
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