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. Ensure an NPO status is maintained for the length of the prescribed treatment: While some ventilated patients are NPO, others receive enteral feeding. NPO status alone does not prevent aspiration.
B. Perform chest physiotherapy as prescribed by the practitioner: Chest physiotherapy helps clear secretions but does not directly reduce aspiration risk.
C. Limit each suctioning event to no more than 10 seconds: While limiting suction time is important to avoid hypoxia, it does not directly prevent aspiration.
D. Elevate the head of the bed between 30 to 45 degrees: Keeping the head of the bed elevated reduces the risk of aspiration, partic
Correct Answer is D
Explanation
A. A 30-year-old rich man: While anyone can develop depression, wealth and younger age generally lower the risk.
B. A 70-year-old married man in a two-income household: Having a supportive spouse and financial stability generally lower depression risk in older adults.
C. A 24-year-old married woman in a single-income home: While financial stress may be a risk factor, younger married individuals tend to have more social support, reducing their overall risk.
D. A 64-year-old single woman: Older women, especially those who are single, widowed, or lacking social support, have an increased risk for depression. The risk is compounded by potential health issues and isolation.
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