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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.

A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.

C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.

D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.

A. The patient has no cough reflex when suctioned. B. The patient's oxygen saturation is 90% to 93% C. The patient does not respond to voice. D. No sedative is ordered for the patient

Correct Answer is D

Explanation

D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.

A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.

B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.

C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?

Correct Answer is B

Explanation

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Correct Answer is D

Explanation

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