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. Decreased cardiac output with increased mean arterial pressure (MAP) does not typically occur in cardiogenic shock. In shock states, MAP tends to decrease.
B. Decreased cardiac output and decreased MAP are the hallmark pathophysiologic changes in cardiogenic shock following a myocardial infarction. The damaged myocardium cannot pump effectively, leading to poor perfusion and hypotension.
C. Increased cardiac output and increased afterload are not features of cardiogenic shock; in fact, cardiac output is decreased.
D. Increased cardiac output and increased MAP suggest improved perfusion, not the compromised state seen in cardiogenic shock.
Correct Answer is A
Explanation
A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.
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