Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?

Stop and ventilate the patient with 100% oxygen.

Check the patient's potassium level

Give prescribed PRN antidysrhythmic medications.

Decrease the suction pressure to 80 mm Hg.

Answer and Explanation

The Correct Answer is A

Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.

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Correct Answer is C

Explanation

Neurogenic shock is a type of distributive shock that occurs due to the loss of sympathetic nervous system tone after a spinal cord injury or other traumatic brain injuries. This loss of sympathetic tone leads to vasodilation and decreased systemic vascular resistance, resulting in inadequate perfusion to vital organs.
One of the hallmark signs of neurogenic shock is bradycardia (a heart rate less than 60 beats/min) due to the unopposed parasympathetic activity. The parasympathetic system becomes dominant when sympathetic activity is impaired. Therefore, a heart rate of 48 beats/min in this patient suggests the possibility of neurogenic shock.
A. Cool, clammy skin in (option A) is incorrect because Cool, clammy skin is a characteristic of hypovolemic shock, where reduced blood volume leads to vasoconstriction to redirect blood flow to vital organs.
B. BP of 82/40 mm Hg in (option B) is incorrect because: Hypotension is a common finding in both neurogenic shock and hypovolemic shock. A low blood pressure reading alone does not specifically indicate neurogenic shock.
D. Shortness of breath in (option D) is incorrect because Shortness of breath is not specific to neurogenic shock but can occur in various types of shock, including hypovolemic shock. It may result from inadequate oxygenation or impaired respiratory function due to the underlying condition or associated injuries.
Therefore, the heart rate of 48 beats/min suggests the possibility of neurogenic shock in addition to hypovolemic shock in this patient.

A. Tachypnoea B. Heart blocks C. Vomiting D. Bradycardia E. Hypotension

Correct Answer is A

Explanation

Tachypnoea, which refers to an increased respiratory rate, is an early symptom of hypovolemic shock. It is the body's compensatory response to inadequate tissue perfusion and decreased oxygen delivery. The increased respiratory rate is an attempt to improve oxygenation and maintain vital organ function.
B. Heart blocks in (option B) are incorrect because Heart blocks refer to disruptions in the electrical conduction system of the heart and are not specific to hypovolemic shock.
C. Vomiting in (option C) is incorrect because: Vomiting may occur in various conditions, including shock, but it is not exclusive to hypovolemic shock and can be present in other forms of shock or illnesses.
D. Bradycardia in (option D) is incorrect because Bradycardia, or a slow heart rate, is not typically an early symptom of hypovolemic shock. Instead, tachycardia (rapid heart rate) is more commonly observed as a compensatory response to maintain cardiac output.
E. Hypotension in (option E) is incorrect because Hypotension, or low blood pressure, can occur in hypovolemic shock but is generally considered a later-stage symptom. In the early stages, compensatory mechanisms may help maintain blood pressure, so hypotension may not be present initially.
F. Bradypnea in (option F) is incorrect because: Bradypnea refers to a slow respiratory rate, which is not typically an early symptom of hypovolemic shock. Tachypnoea, as mentioned earlier, is the more common early respiratory symptom.

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Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?

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