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 ["A","B","D"]
Explanation
Choice A rationale
Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.
Choice B rationale
Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.
Choice C rationale
Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.
Choice D rationale
Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.
Correct Answer is A
Explanation
Choice A rationale
Dyspnea on exertion is the most common initial symptom of pulmonary hypertension. This condition involves increased vascular resistance in the pulmonary arteries, which elevates pressure and makes it more difficult for the right ventricle to pump blood to the lungs. This reduced cardiac output and impaired gas exchange lead to shortness of breath during physical activity.
Choice B rationale
Fever is not a typical manifestation of pulmonary hypertension. Fever is a systemic response to an infectious or inflammatory process. Pulmonary hypertension is a hemodynamic disorder characterized by elevated blood pressure in the lung arteries. While an underlying inflammatory condition could cause fever, fever itself is not a direct symptom of pulmonary hypertension.
Choice C rationale
Increased appetite is not a typical manifestation of pulmonary hypertension. In fact, patients with this condition may experience anorexia, nausea, and vomiting, especially in advanced stages, due to gastrointestinal congestion from right-sided heart failure. Increased appetite is not a recognized symptom and would be an unexpected finding.
Choice D rationale
Intermittent claudication is a symptom of peripheral artery disease, caused by arterial insufficiency in the legs. It presents as leg pain during exercise that is relieved by rest. This is not a manifestation of pulmonary hypertension, which affects the pulmonary circulation and heart, not the systemic arteries supplying the limbs
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