When suctioning a patient, the development of which three clinical manifestations indicates that the nurse would discontinue suctioning immediately?

Shivering

Decreased SpO₂

Absence of coughing

Development of dysrhythmias

Increased blood pressure (BP)

Answer and Explanation

Correct Answer : B,D,C

Choice A reason: Shivering can be a response to various conditions, including cold temperatures or fever, but it is not a direct indicator to discontinue suctioning. While it may be concerning, it does not specifically suggest a problem caused by the suctioning procedure.

Choice B reason: Decreased SpO₂ (oxygen saturation) is a critical sign that the patient is not getting enough oxygen. This condition requires immediate attention, and suctioning should be stopped to assess and address the cause of the hypoxia. Continuing to suction can exacerbate respiratory distress and further lower oxygen levels.

Choice C reason: Absence of coughing is a sign that the patient's airway may be compromised or that the suctioning is too aggressive, potentially leading to further complications. Coughing is a protective reflex that helps clear the airway, and its absence indicates that the airway is not adequately protected, warranting cessation of suctioning.

Choice D reason: Development of dysrhythmias (irregular heartbeats) during suctioning is a serious concern. Dysrhythmias can indicate that the patient is experiencing significant physiological stress or that the vagus nerve is being stimulated, which can impact heart function. Immediate discontinuation of suctioning is necessary to prevent cardiac complications and to stabilize the patient's condition.

Choice E reason: Increased blood pressure, while indicative of stress or pain, is not an immediate indicator to stop suctioning. It should be monitored and addressed, but it does not pose the same immediate risk as decreased oxygen saturation or dysrhythmias.

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Correct Answer is D

Explanation

Choice A reason: Preventing skin maceration is not the primary purpose of the reverse Trendelenburg position. Skin maceration typically occurs due to excessive moisture on the skin, and the bed position does not directly address this issue.

Choice B reason: Reducing restenosis, which is the re-narrowing of a blood vessel after it has been treated, is not directly affected by the patient's bed position. Restenosis is more related to the procedure performed and the patient's overall condition rather than positioning.

Choice C reason: Reducing the risk of infection is also not a direct benefit of the reverse Trendelenburg position. Infection prevention involves maintaining sterile techniques, proper wound care, and monitoring for signs of infection.

Choice D reason: Increasing perfusion to the legs is the correct rationale for placing the bed in the reverse Trendelenburg position for a patient with critical limb ischemia. This position helps to improve blood flow to the lower extremities by utilizing gravity to aid in circulation, thus enhancing oxygen and nutrient delivery to the affected tissues.

A. Administer antibiotics B. Start IV fluids C. Assess pain every 4 hours D. Maintain oxygenation

Correct Answer is D

Explanation

Choice A reason: Administering antibiotics is essential for treating cellulitis to eliminate the infection. However, it is not the immediate priority over maintaining oxygenation, especially in a patient with sickle cell disease.

Choice B reason: Starting IV fluids is crucial for preventing dehydration and helping to reduce the sickling of red blood cells. Nevertheless, while important, it is not the most urgent action compared to maintaining adequate oxygen levels.

Choice C reason: Assessing pain every 4 hours is necessary for managing the patient's comfort and monitoring the progression of the disease. Although pain management is a significant aspect of care, it is not the top priority in this scenario.

Choice D reason: Maintaining oxygenation is the highest priority for a patient with sickle cell disease. These patients are at increased risk for hypoxia, which can exacerbate the sickling of red blood cells, leading to severe complications such as acute chest syndrome or stroke. Ensuring adequate oxygenation helps to prevent these complications and stabilizes the patient's condition.

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When suctioning a patient, the development of which three clinical manifestations indicates that the nurse would discontinue suctioning immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which rationale supports placing the bed in the reverse Trendelenburg position for a patient with critical limb ischemia?

Correct Answer is D

Explanation

A patient with sickle cell disease has developed cellulitis above the left ankle. Which action is the nurse's priority for this patient?

Correct Answer is D

Explanation

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