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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Taking a diuretic before sleep can lead to nocturia (frequent urination at night), disrupting sleep. Also, fluid intake may need to be restricted, not encouraged.
B. Clients with heart failure are usually advised to limit sodium to 2 grams or less per day, not 4 grams, to help reduce fluid retention.
C. Naproxen (a NSAID) is not recommended for clients with heart failure as it can cause fluid retention and worsen the condition.
D. Slowing down when tired after exercise shows an understanding of energy conservation and pacing—appropriate for managing heart failure symptoms. This indicates that teaching was effective.

A. Client with infective endocarditis who has a murmur and splinter hemorrhages B. Client with rheumatic fever who has sharp chest pain with a deep breath C. Client with dilated cardiomyopathy who has bilateral crackles at the lung bases D. Client with acute aortic regurgitation whose blood pressure is 86/54 mm Hg

Correct Answer is D

Explanation

A. A murmur and splinter hemorrhages are expected findings in infective endocarditis and do not indicate an immediate life-threatening condition.
B. Sharp chest pain with inspiration in rheumatic fever may indicate pericarditis, which needs monitoring but is not immediately unstable.
C. Bilateral crackles suggest fluid overload in dilated cardiomyopathy, requiring attention, but not as urgent as hypotension in acute valve failure.
D. Acute aortic regurgitation with hypotension (BP 86/54 mm Hg) indicates a possible hemodynamic collapse and cardiogenic shock, making this client the highest priority for immediate assessment and intervention.

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The nurse notes premature ventricular contractions (PVCs) while suctioning a client's endotracheal tube. Which action by the nurse is a priority?

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