Patient Profile:

• Age: 68 years
• Gender: Male
• Medical History: Hypertension, Type 2 Diabetes Mellitus
• Medications: Lisinopril, Metformin
• Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Exhibits

Choose three parameters the nurse should monitor to assess the patient's progress.

Choice A reason: Shivering can be a response to various conditions, including cold temperatures or fever, but it is not a direct indicator to discontinue suctioning. While it may be concerning, it does not specifically suggest a problem caused by the suctioning procedure.

Choice B reason: Decreased SpO₂ (oxygen saturation) is a critical sign that the patient is not getting enough oxygen. This condition requires immediate attention, and suctioning should be stopped to assess and address the cause of the hypoxia. Continuing to suction can exacerbate respiratory distress and further lower oxygen levels.

Choice C reason: Absence of coughing is a sign that the patient's airway may be compromised or that the suctioning is too aggressive, potentially leading to further complications. Coughing is a protective reflex that helps clear the airway, and its absence indicates that the airway is not adequately protected, warranting cessation of suctioning.

Choice D reason: Development of dysrhythmias (irregular heartbeats) during suctioning is a serious concern. Dysrhythmias can indicate that the patient is experiencing significant physiological stress or that the vagus nerve is being stimulated, which can impact heart function. Immediate discontinuation of suctioning is necessary to prevent cardiac complications and to stabilize the patient's condition.

Choice E reason: Increased blood pressure, while indicative of stress or pain, is not an immediate indicator to stop suctioning. It should be monitored and addressed, but it does not pose the same immediate risk as decreased oxygen saturation or dysrhythmias.

Choice A reason: Asking the patient about loose stools is important as it can help identify possible causes of fluid and electrolyte imbalances. However, this question alone would not be the immediate or primary action to take in response to generalized weakness.

Choice B reason: Suggesting that the healthcare provider order a basic metabolic panel is the most appropriate action. Potassium-wasting diuretics can lead to hypokalemia, which can cause symptoms like generalized weakness. A basic metabolic panel will provide information on the patient's electrolyte levels, including potassium, and help determine if the weakness is due to an electrolyte imbalance. This allows for appropriate intervention to correct the imbalance and prevent further complications.

Choice C reason: Assessing for facial muscle spasms is relevant because hypokalemia can cause muscle cramps and spasms. However, it does not address the root cause of the weakness and does not lead to immediate intervention.

Choice D reason: Calling for a rapid response team is generally reserved for situations where the patient is experiencing acute, life-threatening symptoms requiring immediate intervention. Generalized weakness in the context of a patient on a potassium-wasting diuretic does not usually necessitate such an urgent response unless it progresses to more severe symptoms.