A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Pulse 60

Pulse 90

Oxygen saturation of 92%

Oxygen saturation 89%

Blood pressure 130/80

Answer and Explanation

The Correct Answer is D

A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.

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Correct Answer is B

Explanation

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

A. The client is currently febrile with an oral temperature of 101.2°F B. The client is mildly anxious about their condition. C. The client is reporting feeling nauseated D. The client's pain rated 8 out of 10 on a numerical scale E. The client is asking questions about their health status.

Correct Answer is ["A","C","D"]

Explanation

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

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A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

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