The nurse who is caring for a client in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is:
Ventricular tachycardia
Sinus tachycardia
Supraventricular tachycardia
Sinus bradycardia
The Correct Answer is D
A. Ventricular tachycardia is less commonly triggered by suctioning.
B. Sinus tachycardia may occur but is not the most common arrhythmia during suctioning.
C. Supraventricular tachycardia is not typically associated with suctioning.
D. Sinus bradycardia is the most common arrhythmia caused by vagal stimulation during endotracheal suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Check temperature every 2 hours – While monitoring temperature is important, it is not the priority in cardiogenic shock, which primarily affects cardiac and respiratory function.
B. Auscultate and monitor breath sounds frequently – In cardiogenic shock, pulmonary congestion and fluid overload can develop rapidly due to impaired cardiac output, so frequent assessment of lung sounds is crucial to detect crackles or signs of pulmonary edema.
C. Maintain patient in supine position – A supine position may worsen pulmonary congestion; elevating the head of the bed is typically preferred to improve ventilation and comfort.
D. Assess skin for flushing and itching – This is more relevant in allergic or anaphylactic reactions, not cardiogenic shock.
Correct Answer is D
Explanation
A. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
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