Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates a need for suctioning?
The lungs have occasional audible expiratory wheezes.
The patient has not been suctioned for the last six hours.
The pulse oximeter shows a SpO$_2$ of 93%.
The respiratory rate is 32 breaths/min.
The Correct Answer is D
Choice A rationale
Occasional expiratory wheezes can be a sign of bronchoconstriction but do not necessarily indicate a need for immediate suctioning. Suctioning is primarily indicated for the presence of secretions that obstruct the airway, not for bronchospasm, which is typically treated with bronchodilators.
Choice B rationale
Suctioning is a procedure based on patient assessment findings, not a predetermined schedule. Performing the procedure on a timed basis, without clinical indication, can cause trauma to the tracheal and bronchial mucosa, increasing the risk of infection and bleeding.
Choice C rationale
A pulse oximeter reading of 93% is within the acceptable range for many patients and does not, by itself, indicate the need for suctioning. The need for suctioning is based on the presence of secretions, not solely on oxygen saturation levels, unless there is a significant drop in SpO$_2$.
Choice D rationale
A respiratory rate of 32 breaths/min indicates increased respiratory effort and distress. This tachypnea may be a sign of airway obstruction from secretions, which the patient is trying to clear. The nurse should perform an assessment, including auscultation, and consider suctioning. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5"]
Explanation
The patient has an order for heparin 100 units over one hour. Heparin from the pharmacy comes as 10,000 units in 500 ml. The nurse should set the pump to deliver how many ml/hr?.
Step 1: Calculate the concentration of the heparin solution. 10,000 units ÷ 500 mL = 20 units/mL.
Step 2: Determine the volume of solution required to deliver 100 units. 100 units ÷ (20 units/mL) = 5 mL.
Step 3: The infusion is to be delivered over one hour. 5 mL ÷ 1 hour = 5 mL/hr. The nurse should set the pump to deliver 5 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
Assessing for pain, especially using nonverbal tools, requires clinical judgment and the ability to interpret physiological and behavioral cues. This is a complex nursing skill that involves analysis and critical thinking to determine the appropriate response. Therefore, it is a task that cannot be delegated to UAP, whose scope of practice focuses on basic care and activities of daily living, not complex patient assessments or clinical judgments.
Choice B rationale
Assessing a patient's sedation needs involves evaluating their level of consciousness, response to stimuli, and other clinical indicators to determine if they are adequately sedated or if adjustments are necessary. This is a skilled nursing assessment requiring advanced knowledge of pharmacology and patient physiology. UAP are not trained to perform these assessments and cannot make the clinical judgments required for adjusting or monitoring sedation levels, making delegation unsafe and outside their scope of practice.
Choice C rationale
Obtaining consent, including permission for restraints, is a legal and ethical responsibility of the registered nurse or other licensed healthcare provider. This process involves educating the family about the risks and benefits and ensuring their understanding. It requires a detailed conversation and is beyond the scope of a UAP, who do not have the legal authority or clinical expertise to engage in discussions about informed consent for medical interventions, even non-pharmacological ones.
Choice D rationale
Providing frequent oral care is a supportive and hygienic task that is within the UAP's scope of practice. It involves performing a procedure that follows an established protocol and does not require complex clinical assessment or decision-making. Oral care is crucial for mechanically ventilated patients to prevent ventilator-associated pneumonia by reducing the bacterial load in the mouth, and it is an appropriate task for a UAP to perform under nurse supervision
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