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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Beck's triad consists of three classic clinical manifestations that are suggestive of cardiac tamponade, which is the compression of the heart by accumulated fluid or blood within the pericardial sac. The three components of Beck's triad include:
A. Muffled heart tones in (option A) are incorrect because Cardiac tamponade can dampen or muffle heart sounds due to the presence of fluid or blood around the heart, which can impair sound transmission.
B. Marked hypotension in (option B) is incorrect because Cardiac tamponade can cause decreased cardiac output, leading to hypotension, which is characterized by low blood pressure.
C. Distended jugular veins in (option C) is incorrect because Elevated venous pressure resulting from impaired filling and elevated right-sided heart pressures can lead to jugular vein distension, which is commonly seen in cardiac tamponade.
However, widening pulse pressure (the difference between systolic and diastolic blood pressure) is not typically part of Beck's triad. Widening pulse pressure is associated with her conditions such as aortic regurgitation, hyperthyroidism, or conditions involving increased stroke volume, rather than cardiac tamponade specifically.
Correct Answer is C
Explanation
Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.
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