While suctioning a client, vagal stimulation occurs. What is the appropriate nursing action?
Instruct to cough.
Oxygenate with 100% oxygen.
Place in a high Fowler's position.
Teach to breathe slowly and deeply.
The Correct Answer is B
A. Coughing may exacerbate vagal stimulation, potentially worsening bradycardia or hypotension. This is not a safe immediate action during a vagal response.
B. Vagal stimulation during suctioning can trigger bradycardia, hypotension, or even arrhythmias. The priority nursing action is to stop suctioning immediately and provide 100% oxygen to prevent hypoxemia and maintain tissue perfusion while monitoring the heart rate and vital signs. Supplemental oxygen helps stabilize the patient until the vagal response resolves.
C. While Fowler’s position can improve ventilation, it does not directly counteract vagal stimulation or prevent bradycardia. Positioning alone is insufficient in this acute situation.
D. Teaching deep breathing is a preventative strategy for general respiratory care but is not effective in an acute vagal response. The patient may already be physiologically compromised, making immediate oxygenation and monitoring the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While ABG analysis is important for evaluating oxygenation, ventilation, and acid-base status, it is diagnostic rather than therapeutic. Performing an ABG does not correct the low oxygen saturationor prevent further tissue hypoxia. Therefore, it is a secondary action after initiating oxygen.
B. Oxygen therapy directly addresses the immediate threat of hypoxemia, increasing oxygen delivery to vital organs and tissues. Prompt administration of supplemental oxygen is critical to prevent further deterioration of mental status, organ perfusion, and cardiac function. In a client with sepsis or septic shock, improving oxygenation is a top prioritybefore or during transfer to a higher level of care like the ICU.
C. Treating fever is supportive care but does not resolve hypoxemia or hypotension, which are life-threatening. Fever management is important for comfort and infection control but is secondary to stabilizing oxygenation and perfusion.
D. Continuous cardiac monitoring is important for detecting arrhythmias associated with sepsis or hypoxemia, but it does not intervene in the immediate oxygen deficit. Monitoring alone cannot prevent organ dysfunction caused by low oxygen saturation.
Correct Answer is D
Explanation
A. This flow rate is within the normal range (10–15 L/min) for a nonrebreather mask, which is sufficient to maintain partial inflation of the reservoir bag and deliver high-concentration oxygen.
B. This is normal function. The exhalation ports allow carbon dioxide to escape during exhalation while preventing rebreathing of exhaled air.
C. This is expected and appropriate. Closing the exhalation ports during inhalation ensures the patient draws oxygen from the reservoir bag rather than room air.
D. A collapsed bag indicates that the patient is not receiving adequate high-concentration oxygen, which can quickly lead to hypoxemia and respiratory compromise. Causes may include low oxygen flow, a loose mask, or tubing obstruction. Immediate intervention is required to check the oxygen source, ensure proper mask fit, inspect tubing for kinks or disconnections, and monitor oxygen saturation.
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