During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Administer Atropine.

Call the health care provider immediately.

Continue to clear the airway.

Stop suctioning the patient.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering Atropine can increase the heart rate, but it is not the immediate first action. The priority is to stop the stimulus causing the vagal response, which in this case is the suctioning.

Choice B reason:

Calling the healthcare provider is important, but the immediate action should be to stop the suctioning to eliminate the cause of the vagal response. Once the immediate issue is addressed, notifying the provider can follow.

Choice C reason:

Continuing to clear the airway can exacerbate the vagal response and worsen the patient's condition. The immediate action should be to stop the suctioning.

Choice D reason:

Stopping the suctioning is the best immediate action to take when the patient becomes diaphoretic, nauseous, and experiences a significant drop in heart rate. This response is likely due to vagal stimulation, and stopping the suctioning will help alleviate the symptoms.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

A. Apply oxygen at 100%. B. Assess the heart rate. C. Ensure a patent airway. D. Start two large-bore IV lines.

Correct Answer is C

Explanation

Choice A reason:

Applying oxygen at 100% is an important step in managing a patient with a life-threatening chest injury. However, ensuring a patent airway is the first priority, as it is crucial to maintain airway patency to facilitate oxygen delivery. Without an open airway, oxygen administration would be ineffective.

Choice B reason:

Assessing the heart rate is part of the initial assessment in emergency care. However, the priority is to ensure a patent airway, as a compromised airway can lead to hypoxia and rapid deterioration of the patient's condition. Heart rate assessment can follow once airway patency is confirmed.

Choice C reason:

Ensuring a patent airway is the top priority in the emergency management of a patient with a life-threatening chest injury. Airway patency is essential for effective ventilation and oxygenation. If the airway is obstructed, the patient cannot receive oxygen or expel carbon dioxide, leading to life-threatening complications.

Choice D reason:

Starting two large-bore IV lines is important for fluid resuscitation and medication administration. However, the primary focus should be on ensuring a patent airway, as immediate airway management is critical to the patient's survival in the acute phase of a life-threatening chest injury.

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During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Correct Answer is ["B","C","D"]

Explanation

A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Correct Answer is C

Explanation

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