After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Clear breath sounds on auscultation.

Increased respiratory rate.

Decreased oxygen saturation.

Presence of wheezing.

Answer and Explanation

The Correct Answer is A

Choice A reason: Clear breath sounds indicate effective suctioning, as it removes secretions obstructing the airway, improving ventilation. This aligns with the goal of endotracheal suctioning to maintain airway patency, ensuring adequate oxygenation and reducing infection risk, per critical care and respiratory management protocols in nursing practice.

Choice B reason: Increased respiratory rate suggests respiratory distress, indicating ineffective suctioning. Clear breath sounds confirm secretion removal, ensuring airway patency. A rising rate may reflect persistent obstruction or hypoxia, requiring further intervention, per respiratory assessment and critical care standards for endotracheal tube management in nursing.

Choice C reason: Decreased oxygen saturation indicates ineffective suctioning, as secretions likely remain, impairing oxygenation. Clear breath sounds confirm airway clearance, improving gas exchange. Low saturation requires immediate reassessment, per oxygenation monitoring and critical care protocols for clients with endotracheal tubes in nursing practice.

Choice D reason: Presence of wheezing suggests airway narrowing or persistent secretions, indicating ineffective suctioning. Clear breath sounds demonstrate successful secretion removal, ensuring unobstructed airflow. Wheezing requires further intervention, per respiratory assessment and airway management standards in critical care nursing for intubated clients.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: A blood pressure of 100/80 mm Hg is low but not specific for renal perfusion without context. Urinary output directly reflects kidney function, with 30 mL/hour indicating possible oliguria. Monitoring output is critical, per renal assessment and acute kidney injury management protocols in nursing care.

Choice B reason: Abdominal pulse on inspection is unrelated to renal perfusion, typically indicating vascular issues like aneurysms. Urinary output is a direct indicator of kidney function, with 30 mL/hour suggesting reduced perfusion. This is irrelevant, per renal assessment and diagnostic standards in nephrology nursing.

Choice C reason: Urinalysis with 1 to 4 WBC/lpf is within normal range and suggests no infection. Urinary output of 30 mL/hour is concerning for decreased renal perfusion, requiring close monitoring. WBCs are less critical, per renal function and acute kidney injury assessment guidelines in nursing.

Choice D reason: Urinary output of 30 mL/hour indicates possible oliguria, a key sign of decreased renal perfusion. Monitoring this parameter assesses kidney function, guiding interventions to prevent acute kidney injury. It is the most direct indicator, per renal perfusion and critical care protocols in nephrology nursing practice.

A. Place the chair by the bed. B. Support the client when rising. C. Determine how the client feels. D. Offer a pair of non-skid socks.

Correct Answer is C

Explanation

Choice A reason: Placing the chair by the bed is preparatory but not immediate after sitting up. Prolonged bedrest risks orthostatic hypotension from reduced plasma volume and baroreceptor sensitivity. Assessing the client’s response ensures stability before transfer, preventing falls, making this less urgent than evaluating for dizziness or hypotension.

Choice B reason: Supporting the client when rising is premature before assessing their response to sitting. Bedrest causes deconditioning, increasing orthostatic hypotension risk, leading to dizziness or syncope. Determining how the client feels confirms cardiovascular stability, preventing falls during transfer due to blood pressure drops.

Choice C reason: Determining how the client feels assesses for orthostatic hypotension, common post-bedrest due to reduced venous return and baroreceptor dysfunction. Dizziness or lightheadedness signals syncope risk during transfer. This ensures cardiovascular stability, prioritizing safety before physical support, addressing physiological changes from prolonged immobility.

Choice D reason: Offering non-skid socks prevents falls during ambulation but is secondary to assessing sitting response. Bedrest heightens hypotension risk, and ensuring the client is not dizzy takes precedence to avoid syncope. Socks are a later safety measure, making this less immediate than evaluating physiological stability.

View Question and Answer

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

After suctioning a client who has an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is admitted to the renal unit with suspected decreased renal perfusion. The nurse should plan to carefully monitor which parameter? Reference Range: Urine white blood cells (WBC) [0 to 4 WBC/low powered field (lpf)]

Correct Answer is D

Explanation

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

Correct Answer is C

Explanation

The nurse is caring for a client with a new tracheostomy. Which action is most important to include in the client’s plan of care?

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

On the second postoperative day, a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. Which intervention should the nurse anticipate implementing?

An older adult client, who is insulin-dependent, arrives at the diabetic clinic with concerns of thick, crusty, and long toenails that are piercing the adjacent toes. Which action should the nurse take?

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

A client who had a radical neck dissection returns to the surgical unit with two surgical drains in the right side of the incision. One drain bulb is open and has minimal drainage. Which action should the nurse take to increase drainage into the drain?