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 B

Explanation

A. Metabolic acidosis: Metabolic acidosis typically results from a condition like renal failure or diabetic ketoacidosis, where there is a decrease in bicarbonate or an increase in acid. Shallow and slow respirations are more indicative of respiratory acidosis.

B. Respiratory acidosis: Shallow and slow respirations (9/min) reduce the effectiveness of ventilation, leading to the accumulation of carbon dioxide (CO2) in the blood. The increased CO2 leads to a decrease in pH, causing respiratory acidosis.

C. Respiratory alkalosis: Respiratory alkalosis occurs when there is rapid or deep breathing, leading to excessive exhalation of CO2. Since the client has shallow and slow respirations, they are more at risk for respiratory acidosis, not alkalosis.

D. Metabolic alkalosis: Metabolic alkalosis is caused by conditions such as vomiting or excessive use of diuretics, which lead to an increase in bicarbonate. It is not typically associated with slow, shallow respirations.

A. Blood pressure 110/72 mm Hg B. Intracranial pressure (ICP) 25 mm Hg C. PaC02 35 mm Hg D. Pulse oximetry 96%

Correct Answer is B

Explanation

A. Blood pressure 110/72 mm Hg: A blood pressure of 110/72 mm Hg is within the normal range and does not require intervention. Maintaining a stable blood pressure is essential after a craniotomy, and this reading indicates no immediate concerns.

B. Intracranial pressure (ICP) 25 mm Hg: An ICP of 25 mm Hg is above the normal range (typically 5-15 mm Hg). Elevated ICP can lead to brain herniation and other severe complications. The nurse should notify the healthcare provider immediately and take measures to reduce ICP, such as positioning and administering medications if needed.

C. PaCO2 35 mm Hg: A PaCO2 of 35 mm Hg is within the normal range (35-45 mm Hg). The normal level of carbon dioxide is important for maintaining appropriate cerebral perfusion pressure, and this value does not indicate a problem.

D. Pulse oximetry 96%: A pulse oximetry reading of 96% is within the normal range (95-100%) and indicates adequate oxygenation. No immediate intervention is needed unless the value drops significantly below this level.

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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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