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 D
Explanation
A. Employer. An employer is not a unique patient identifier.
B. Medical record number. A medical record number is a unique identifier and is a recommended method for verifying the right patient.
C. Maiden name. A maiden name is not a reliable identifier, as patients may change names over time.
D. Date of birth: The date of birth is a critical and commonly used patient identifier, often paired with another piece of information (such as name or medical record number). It is specific and unique to the patient, making it ideal for ensuring the right individual receives care.
Correct Answer is A
Explanation
A. "I will use this device 20 times per hour while I am awake each day.": Correct. This statement requires correction. While frequent use is recommended, 10 times per hour is typically sufficient. Overuse may cause hyperventilation or dizziness.
B. "I should be in a sitting position when using this device.": Correct. A sitting or semi-Fowler’s position promotes lung expansion and is the proper position for using an incentive spirometer.
C. "I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.": Correct. Holding the breath allows for alveolar expansion and better lung recruitment.
D. "I will exhale completely before placing my lips around the mouthpiece.": Correct. Exhaling fully ensures that the next inhalation is deep and effective.
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