Which nursing action would be the highest priority when suctioning a patient with an oral endotracheal (ET) tube or tracheostomy?
Give antianxiety medications 30 minutes before suctioning.
Instill 5 ml of normal saline into the tube before suctioning.
Hyperoxygenate with 100 percent FiO2 before suctioning.
Auscultate lung sounds after suctioning is complete.
The Correct Answer is C
Choice A rationale
Administering antianxiety medication is a comfort measure but does not address the immediate physiological risks associated with suctioning. Suctioning induces transient hypoxia and increases myocardial oxygen demand, which can lead to dysrhythmias. While reducing patient distress is important for overall care, it is not the highest priority when compared to maintaining adequate cellular oxygenation during an invasive procedure that actively removes oxygen from the airway.
Choice B rationale
Instilling normal saline into the endotracheal tube was once common practice but is now discouraged because it does not effectively thin secretions. Instead, it can displace bacteria from the inner lumen of the tube deeper into the lower respiratory tract, increasing the risk of ventilator-associated pneumonia. It also decreases oxygen saturation significantly. Hydration and humidification are the preferred systemic methods for managing thick pulmonary secretions in intubated patients.
Choice C rationale
Suctioning removes both secretions and oxygen from the airway, which can lead to severe hypoxemia, bradycardia, or even cardiac arrest. Providing 100 percent FiO2 for at least 30 to 60 seconds prior to the procedure creates an oxygen reserve in the lungs. This prevents the hemoglobin saturation from dropping to dangerous levels during the periods of apnea and negative pressure. This action is the highest priority to ensure patient safety.
Choice D rationale
Auscultation is a necessary assessment to evaluate the effectiveness of the suctioning procedure and to ensure the airway is clear. However, it is an evaluative step performed after the intervention has occurred. While it helps determine if further suctioning is required, it does not prevent the immediate life-threatening complications of hypoxia that occur during the procedure itself. Therefore, it remains secondary to the proactive step of pre-oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This rhythm originates above the ventricles, typically from the atrioventricular node or atria, characterized by narrow QRS complexes and a regular rhythm. In the provided strip, the absence of discernible P waves and a grossly irregular ventricular response contradicts this diagnosis. Additionally, the rate calculation based on a six second strip requires counting R waves and multiplying by ten, which leads to a specific frequency not matching this option's tachycardia profile.
Choice B rationale
This rhythm involves a regular discharge from the sinoatrial node exceeding 100 beats per minute, usually displaying identifiable P waves before every narrow QRS complex. Normal sinus rhythm features regular R-R intervals, whereas the strip demonstrates significant irregularity. Tachycardia at 150 bpm is common in stress or fever, but the chaotic nature of the atrial activity and the irregular ventricular rate on the monitor strip point toward a more disorganized supraventricular arrhythmia rather than sinus.
Choice C rationale
This life threatening rhythm is defined by a wide QRS complex (>0.12 seconds) originating from ventricular ectopic foci, typically presenting as a regular, rapid rhythm. The strip shows narrow QRS complexes, which indicates that the electrical impulse is traveling through the normal conduction system rather than originating in the ventricles. A rate of 210 bpm is possible, but the narrow morphology and irregular spacing definitively rule out a primary ventricular origin for this rhythm.
Choice D rationale
This condition is characterized by disorganized atrial electrical activity resulting in no distinct P waves and an irregularly irregular ventricular rhythm. Rapid ventricular response occurs when the atrioventricular node allows numerous impulses to pass, exceeding 100 bpm. By counting the R waves in a six second strip and multiplying by ten, a rate of 210 bpm is confirmed. The baseline shows fibrillatory waves, and the R-R intervals are inconsistent, making this the most accurate clinical diagnosis.
Correct Answer is D
Explanation
Choice D rationale
To ensure the accuracy of the hemodynamic data from a radial arterial line, the nurse must reference and zero the system. Referencing involves positioning the transducer at the phlebostatic axis, which is the level of the atria at the fourth intercostal space, mid-axillary line. Zeroing the line negates the effects of atmospheric pressure on the monitoring system. This ensures that the pressure displayed on the monitor represents only the patient's internal physiological blood pressure, preventing false high or low readings.
Choice A rationale
Flushing the arterial line is done to maintain patency of the catheter and clear the tubing of blood after sampling. However, a continuous flush system usually handles this at a rate of 3 mL per hour. Manually flushing for 10 seconds is not a standard requirement prior to taking a reading and could potentially cause a fluid bolus or damage the artery if done with excessive force. It does not contribute to the calibration or accuracy of the electronic pressure transducer.
Choice B rationale
While positioning is important, the correct landmark for hemodynamic monitoring is the phlebostatic axis, not the sternal angle. The sternal angle, or Angle of Louis, is used as a landmark for identifying the second rib and auscultating heart sounds, but it does not correspond to the level of the heart's chambers for pressure monitoring. Using the incorrect reference point will lead to hydrostatic pressure errors, where every inch the transducer is below the heart adds approximately 2 mmHg to the reading.
Choice C rationale
The Allen test is a diagnostic physical exam used to assess the patency of the ulnar artery and the adequacy of collateral circulation to the hand. This must be performed before the arterial line is even inserted into the radial artery to ensure that the hand will remain perfused if the radial artery becomes occluded. Once the line is already in place, performing an Allen test is not a prerequisite for obtaining a routine pressure reading from the monitor.
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