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 D
Explanation
A. Mitral valve prolapse often requires no treatment or is managed with medications; balloon valvuloplasty is not typically used.
B. Aortic regurgitation usually requires surgical valve replacement rather than valvuloplasty.
C. Mitral regurgitation involves backward blood flow and is generally treated with valve repair or replacement, not balloon valvuloplasty.
D. Mitral stenosis is most commonly treated with balloon valvuloplasty, especially in clients with rheumatic heart disease. This procedure helps open a narrowed mitral valve by inflating a balloon within the valve to improve blood flow.
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