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 C
Explanation
A. Financial stability: Financial stability is a protective factor against suicide.
B. Engaging in extracurricular activities: Social involvement and participation in activities generally reduce suicide risk.
C. Loss of a job: Job loss is a significant psychosocial stressor that can contribute to feelings of hopelessness, depression, and suicidal ideation.
D. Exercising caution in behavior: Individuals at risk for suicide often engage in impulsive or risky behavior, not cautious behavior.
Correct Answer is D
Explanation
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
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