The nurse notes premature ventricular contractions (PVCs) while suctioning a client's endotracheal tube. Which action by the nurse is a priority?
Stop and ventilate the patient with 100% oxygen.
Give antidysrhythmic medications per protocol.
Decrease the suction pressure to 80 mm Hg.
Document the dysrhythmia in the patient's chart.
The Correct Answer is A
A. PVCs during suctioning may indicate hypoxia or irritation; the priority is to stop suctioning and ventilate the patient with 100% oxygen to prevent worsening arrhythmias.
B. Medications may be needed later, but immediate action is oxygenation and stopping suctioning.
C. Adjusting suction pressure is important but secondary to ensuring patient oxygenation.
D. Documentation is necessary but not the priority when PVCs are noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ventricular tachycardia presents with wide QRS complexes and a fast ventricular rate, but not sawtooth P waves.
B. Atrial flutter is characterized by a rapid atrial rate (typically around 250–350 beats/min) and "sawtooth" flutter waves on the ECG. The ventricular response is often regular, as seen in this client with a ventricular rate of 82 beats/min.
C. Atrial fibrillation presents with an irregularly irregular rhythm and absent P waves, replaced by fibrillatory waves — not the sawtooth pattern described here.
D. Ventricular fibrillation shows chaotic, irregular, and disorganized electrical activity with no identifiable P waves, QRS complexes, or T waves, and would not present as a stable rhythm with a ventricular rate of 82 bpm.
Correct Answer is A
Explanation
A. The presence of prosthetic heart valves is a significant risk factor for infective endocarditis due to the increased likelihood of bacterial colonization.
B. Sedentary lifestyle is not a direct risk factor for infective endocarditis, though it may contribute to other cardiovascular issues.
C. Radiation exposure – While it may affect cardiac tissue, it is not considered a risk factor for infective endocarditis.
D. Cardiac catheterization – While it is an invasive procedure, it is not a major or common risk factor for infective endocarditis compared to prosthetic valves or structural heart defects.
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