The nurse performs in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?
Discontinue suctioning and administer 100% oxygen
Discontinue suctioning and prepare for resuscitation
Continue suctioning and administer 50% oxygen
Continue suctioning and administer prescribed epinephrine
The Correct Answer is A
A. Discontinue suctioning and administer 100% oxygen: A drop in oxygen saturation and bradycardia indicates the patient is not tolerating suctioning. The priority is to stop suctioning and administer 100% oxygen to prevent hypoxia.
B. Discontinue suctioning and prepare for resuscitation: While severe cases may require resuscitation, the immediate intervention is oxygen administration, not premature resuscitation efforts.
C. Continue suctioning and administer 50% oxygen: Continuing suctioning may worsen hypoxia and bradycardia. Administering 50% oxygen may not be sufficient in a critical situation.
D. Continue suctioning and administer prescribed epinephrine: Epinephrine is used for anaphylaxis and severe cardiac issues, not for managing suction-related hypoxia.
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Related Questions
Correct Answer is D
Explanation
A. Assessment, diagnosis, intervention, evaluation, discharge, documentation. Discharge and documentation are important but are not part of the core nursing process.
B. Assessment, planning, intervention, evaluation, discharge, follow-up. Follow-up is not a standard step in the nursing process.
C. Assessment, diagnosis, planning, interventions, evaluation, education. Education is important but is not one of the six standard nursing process steps.
D. (Re)Assessment, diagnosis, outcomes, planning, implementation, evaluation. This accurately outlines the nursing process, which involves reassessing the patient, diagnosing, setting expected outcomes, planning care, implementing interventions, and evaluating effectiveness.
Correct Answer is D
Explanation
A. Employer. An employer is not a unique patient identifier.
B. Medical record number. A medical record number is a unique identifier and is a recommended method for verifying the right patient.
C. Maiden name. A maiden name is not a reliable identifier, as patients may change names over time.
D. Date of birth: The date of birth is a critical and commonly used patient identifier, often paired with another piece of information (such as name or medical record number). It is specific and unique to the patient, making it ideal for ensuring the right individual receives care.
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