When suctioning a patient, the development of which three clinical manifestations indicates that the nurse would discontinue suctioning immediately?
Shivering
Decreased SpO₂
Absence of coughing
Development of dysrhythmias
Increased blood pressure (BP)
Correct Answer : B,D,C
Choice A reason: Shivering can be a response to various conditions, including cold temperatures or fever, but it is not a direct indicator to discontinue suctioning. While it may be concerning, it does not specifically suggest a problem caused by the suctioning procedure.
Choice B reason: Decreased SpO₂ (oxygen saturation) is a critical sign that the patient is not getting enough oxygen. This condition requires immediate attention, and suctioning should be stopped to assess and address the cause of the hypoxia. Continuing to suction can exacerbate respiratory distress and further lower oxygen levels.
Choice C reason: Absence of coughing is a sign that the patient's airway may be compromised or that the suctioning is too aggressive, potentially leading to further complications. Coughing is a protective reflex that helps clear the airway, and its absence indicates that the airway is not adequately protected, warranting cessation of suctioning.
Choice D reason: Development of dysrhythmias (irregular heartbeats) during suctioning is a serious concern. Dysrhythmias can indicate that the patient is experiencing significant physiological stress or that the vagus nerve is being stimulated, which can impact heart function. Immediate discontinuation of suctioning is necessary to prevent cardiac complications and to stabilize the patient's condition.
Choice E reason: Increased blood pressure, while indicative of stress or pain, is not an immediate indicator to stop suctioning. It should be monitored and addressed, but it does not pose the same immediate risk as decreased oxygen saturation or dysrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Asking the patient to try bearing weight on the injured ankle is not appropriate at this stage. Bearing weight can cause further injury or exacerbate the swelling and pain. The initial treatment should focus on reducing swelling and providing support.
Choice B reason: Elevating the ankle above heart level is appropriate because it helps to reduce swelling by promoting venous return and decreasing fluid accumulation in the affected area. Elevation is a standard first aid measure for managing acute injuries and swelling.
Choice C reason: Applying a warm moist pack to the ankle is not advisable immediately after an injury. In the acute phase, cold therapy (ice) is recommended to reduce swelling and pain. Warm therapy is more appropriate during the recovery phase, once swelling has subsided.
Choice D reason: Assessing the ankle's passive range of motion (ROM) may be necessary later, but not immediately upon arrival. The priority is to manage pain and swelling first. ROM assessments can be painful and might worsen the injury if conducted too soon.
Correct Answer is B
Explanation
Choice A reason: Kidney failure is not a common immediate complication related to the patient's presentation of sudden right-sided weakness and difficulty speaking, which are indicative of a stroke. Although diabetes and hypertension can eventually lead to kidney issues, this is not an acute complication.
Choice B reason: Aspiration pneumonia is a potential complication of the patient's condition, especially given the presence of expressive aphasia. Patients with neurological deficits, particularly those affecting speech and swallowing, are at higher risk of aspirating food or liquids into the lungs, leading to pneumonia.
Choice C reason: Hypotension is not commonly a direct complication of a stroke, especially considering the patient's elevated blood pressure. Stroke patients often present with hypertension rather than hypotension.
Choice D reason: Heart failure, while related to the patient's underlying conditions like hypertension and possibly diabetes, is not an immediate complication of the acute neurological event described. The focus should be more on the neurological and respiratory complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.