Which assessment finding obtained by the nurse when caring for a client receiving mechanical ventilation indicates the need for suctioning?

The client was last suctioned 6 hours ago

The client's respiratory rate is 32 breaths/min

The client has occasional audible expiratory wheezes

The client's oxygen saturation drops to 95%

Answer and Explanation

The Correct Answer is B

A. The client was last suctioned 6 hours ago: Time alone doesn’t indicate the need for suctioning. Suctioning is performed based on assessment findings, not routine schedules.

B. The client's respiratory rate is 32 breaths/min: A rapid respiratory rate can signal airway obstruction, secretions, or respiratory distress—all of which may require suctioning to improve ventilation.

C. The client has occasional audible expiratory wheezes: Wheezes suggest lower airway narrowing, which typically doesn’t improve with suctioning. Suctioning targets upper airway secretions, not bronchospasm.

D. The client's oxygen saturation drops to 95%: A saturation of 95% is still within normal limits and doesn't, by itself, suggest the need for suctioning unless accompanied by other signs like crackles, visible secretions, or distress.

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Correct Answer is C

Explanation

A. Respiratory rate 20/min: A respiratory rate of 20/min is within the normal range for an adolescent. While respiratory function should always be monitored, this finding is not alarming in the context of blunt trauma.

B. Heart rate 72/min: A heart rate of 72/min is within the normal range for an adolescent. This does not indicate immediate concern, and the patient’s heart rate is stable.

C. Blood pressure 89/50 mm Hg: A blood pressure of 89/50 mm Hg is low and indicates potential shock, which is a life-threatening concern. Hypotension following blunt abdominal trauma can suggest internal bleeding or organ injury, which requires immediate intervention.

D. Abdominal pain rated 4 on a scale of 0 to 10: While abdominal pain is a concern, a pain level of 4/10 is not immediately life-threatening. The priority is addressing the low blood pressure, which could indicate shock or internal bleeding, requiring urgent medical attention.

A. Initiate client decontamination B. Place the clients in isolation. C. Administer antibiotic therapy D. Treat clients with an antitoxin

Correct Answer is C

Explanation

A. Initiate client decontamination: While decontamination might seem intuitive, anthrax (Bacillus anthracis) is primarily acquired through inhalation of spores, ingestion, or skin contact with spores. It is not contagious from person to person. Therefore, routine external decontamination of is not necessary.

B. Place the clients in isolation: Isolation may be necessary for individuals who are showing symptoms of anthrax, but for those who may have been exposed without symptoms, antibiotic therapy is more urgent. Isolation would follow if clinical signs of infection develop.

C. Administer antibiotic therapy: After potential exposure to anthrax, the appropriate action is to administer prophylactic antibiotics, such as ciprofloxacin or doxycycline. Antibiotics are the first line of defense to prevent the infection, particularly exposure.

D. Treat clients with an antitoxin: Antitoxins are used in cases where infection is confirmed and symptoms are present, particularly in severe forms of anthrax. However, administering antibiotics for prophylaxis is the initial and most important action.

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Which assessment finding obtained by the nurse when caring for a client receiving mechanical ventilation indicates the need for suctioning?

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