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 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.
Correct Answer is B
Explanation
B. The QT interval represents ventricular depolarization and repolarization. It starts at the beginning of the QRS complex and ends at the end of the T wave. The QT interval reflects the total time it takes for both ventricular depolarization and repolarization to occur. Prolongation of the QT interval can be associated with an increased risk of arrhythmias, including torsades de pointes.
A. The QRS complex represents ventricular depolarization, which is the electrical activation of the ventricles. The duration of the QRS complex provides information about the time it takes for ventricular depolarization to occur. A prolonged QRS complex can indicate abnormalities in ventricular conduction, such as bundle branch blocks or ventricular hypertrophy.
C. The ST segment represents the early part of ventricular repolarization. It starts at the end of the QRS complex and ends at the beginning of the T wave. Changes in the ST segment, such as elevation or depression, can indicate myocardial ischemia or injury.
D. The PR interval represents the time it takes for the electrical impulse to travel from the atria to the ventricles. It includes atrial depolarization, atrial contraction, and the delay at the atrioventricular node. The PR interval does not specifically provide information about ventricular depolarization and repolarization.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today