A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Obtain a cardiology consult.
Perform pre-oxygenation prior to suctioning.
Suction the client less frequently.
Administer an antidysrhythmic medication.
The Correct Answer is B
B. This is advised to prevent hypoxemia, which can manifest as tachycardia and arrhythmia, conditions indicated by an increased and irregular heart rate. Pre-oxygenation helps maintain adequate oxygen levels in the blood, which can be compromised during the suctioning process.
A. Obtaining a cardiology consult might be necessary if the client's heart rate increases and becomes irregular. However, it's not the immediate action the nurse should take. This option is more appropriate for addressing the underlying cause of the client's dysrhythmia rather than the immediate management during suctioning.
C. Suctioning the client less frequently might be appropriate if the client's response to suctioning is causing distress or physiological changes like increased heart rate. However, if suctioning is necessary due to secretions in the airway, simply reducing the frequency might not be sufficient to address the client's cardiovascular response.
D. Administering an antidysrhythmic medication should be considered if the client's heart rate increases and becomes irregular during or after suctioning, especially if the dysrhythmia persists or worsens.
However, this should be done under the guidance of a healthcare provider and after assessing the client's overall condition, including potential causes of the dysrhythmia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
B. This is an essential nursing intervention to ensure that the ventilator is delivering the appropriate settings as ordered by the healthcare provider. Ventilator settings may need to be adjusted based on the client's condition, so daily verification is important for patient safety and optimal ventilator management.
D. Pantoprazole is a proton pump inhibitor commonly used to prevent stress ulcers in critically ill patients receiving mechanical ventilation. It helps reduce gastric acid secretion and can prevent complications such as gastrointestinal bleeding. Administering pantoprazole as prescribed is an appropriate intervention to prevent complications related to stress ulcers in ventilated patients.
E. Elevating the head of the bed to at least 30 degrees is a crucial intervention to prevent ventilator- associated pneumonia (VAP) by reducing the risk of aspiration. This position helps promote drainage of oral and gastric secretions, reducing the likelihood of aspiration into the lungs. It's considered a standard practice in ventilated patients to minimize the risk of pulmonary complications.
A. Apply restraints if the client becomes agitated: While it may be necessary to use restraints in certain situations to ensure the safety of the client and prevent self-extubation or injury, they should be used judiciously and only when other measures to manage agitation have failed. Restraints should not be the first-line intervention and should be used in accordance with facility policies and regulations.
C. Repositioning the endotracheal tube to the opposite side of the mouth daily is not a standard nursing intervention. Once the endotracheal tube is properly positioned and secured, it should not routinely need to be repositioned unless clinically indicated due to complications such as mucosal irritation or tube displacement.
Correct Answer is A
Explanation
A In atrial fibrillation (AF), the electrical activity in the atria is chaotic, leading to an irregularly irregular ventricular response. As a result, the pulse felt at the radial artery will be irregular, with no discernible pattern. The irregularity is a hallmark feature of AF and is often described as "irregularly irregular."
B Bounding pulses are characterized by a strong and forceful pulsation felt at the arterial pulse sites. In atrial fibrillation, the irregular and rapid ventricular response can lead to an increased stroke volume and forceful contraction of the left ventricle during diastole, resulting in bounding pulses. However, bounding pulses are not typically associated with atrial fibrillation; they are more commonly seen in conditions such as aortic regurgitation or hyperdynamic circulation.
C In some cases of atrial fibrillation, especially if the ventricular rate is very rapid or irregularly irregular, the pulse may not be palpable due to the inconsistent ventricular contractions.
However, in most cases of atrial fibrillation, a pulse is palpable, albeit irregular.
D Atrial fibrillation can result in a rapid ventricular response, leading to a fast heart rate. However, the pulse rate can vary widely among individuals with atrial fibrillation. While some may have a rapid heart rate (tachycardia), others may have a slower heart rate (bradycardia), depending on factors such as concomitant medications, autonomic tone, and the presence of underlying heart disease.
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