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 D

Explanation

D Normal saline bolus administration is indicated for hypovolemia or inadequate intravascular volume, which can lead to decreased cardiac output and hypotension. In this scenario, the client has an amber urine output of 45ml in the last 3 hours, indicating decreased urine output and potential hypovolemia. The elevated blood pressure (170/67 mmHg) suggests possible volume overload or fluid retention, but the decreased urine output raises concerns for inadequate intravascular volume. Therefore, administering a normal saline bolus may be the first priority to optimize intravascular volume and improve cardiac output.

A Isosorbide mononitrate is a vasodilator commonly used in the treatment of heart failure and angina. It helps reduce preload and afterload, thereby decreasing the workload on the heart. However, in this scenario, the client's blood pressure is elevated (170/67 mmHg), and there is no indication of acute decompensation or pulmonary congestion. Therefore, isosorbide PO may not be the first priority medication at this time.

B Nitroglycerin is a potent vasodilator commonly used to manage acute heart failure exacerbations and acute coronary syndromes. It helps reduce preload and afterload, improving cardiac output and relieving symptoms of heart failure. In this scenario, the client's blood pressure is elevated, but the heart rate is normal, and there are no signs of acute decompensation. Therefore, initiating a nitroglycerin drip may not be the first priority unless the client develops symptoms of acute decompensation or pulmonary congestion.

C Dopamine is a vasopressor medication that can be used to increase blood pressure and cardiac output in patients with hypotension or shock. However, in this scenario, the client's blood pressure is elevated (170/67 mmHg), and there is no evidence of hypotension. Therefore, initiating a dopamine drip may not be appropriate at this time and could potentially exacerbate hypertension.

A. Pulmonary artery wedge pressure (PAWP) is low. B. Systemic vascular resistance (SVR) is elevated. C. Mean arterial pressure (MAP) is 56 mm Hg D. Heart rate is slow at 58 beats/min.

Correct Answer is C

Explanation

C. Mean arterial pressure (MAP) reflects the average pressure in the arteries during one cardiac cycle and is an important indicator of tissue perfusion. A MAP of 56 mm Hg is below the normal range (typically >60 mm Hg) and may indicate inadequate tissue perfusion. While norepinephrine is commonly used to increase blood pressure and improve tissue perfusion in hypotensive patients, a MAP of 56 mm Hg suggests that the current infusion rate may not be sufficient to maintain adequate perfusion, and adjusting the infusion rate may be warranted.

A. Norepinephrine is a vasopressor medication primarily used to increase blood pressure in patients with hypotension or shock. A low pulmonary artery wedge pressure (PAWP) suggests decreased preload, which may indicate hypovolemia or inadequate fluid resuscitation. In this case, adjusting the norepinephrine infusion rate may not be necessary, but rather addressing the underlying cause of hypovolemia or inadequate preload.

B. Systemic vascular resistance (SVR) represents the resistance the heart must overcome to pump blood into the systemic circulation. An elevated SVR may suggest vasoconstriction, which could be a desired effect of norepinephrine infusion to increase blood pressure. Therefore, an elevated SVR may not necessarily indicate a need to adjust the norepinephrine infusion rate, as it may reflect the medication's intended action.

D. Norepinephrine primarily acts on alpha-adrenergic receptors to increase blood pressure by inducing vasoconstriction. While it may cause reflex bradycardia due to increased systemic vascular resistance, a heart rate of 58 beats/min may be within an acceptable range depending on the patient's clinical condition and baseline heart rate. Therefore, a slow heart rate alone may not necessarily indicate a need to adjust the norepinephrine infusion rate unless it is associated with signs of inadequate tissue perfusion or other concerning symptoms.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

Correct Answer is D

Explanation

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

Correct Answer is C

Explanation

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