Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?
The patient has occasional audible expiratory wheezes.
The patient's respiratory rate is 32 breaths/min
The patient was last suctioned 6 hours ago.
The patient's oxygen saturation drops to 93%.
The Correct Answer is D
D. A drop in oxygen saturation may indicate inadequate oxygenation, which could be due to airway obstruction or retained secretions.
A. While audible expiratory wheezes may indicate airway obstruction or secretions, they do not necessarily indicate the need for suctioning in a patient receiving mechanical ventilation.
B. An elevated respiratory rate may suggest increased work of breathing, which could be due to retained secretions or airway obstruction. However, an elevated respiratory rate alone may not always indicate the need for suctioning.
C. The timing of the last suctioning episode is an important consideration when determining the need for suctioning. However, it should not be the sole indicator for when to suction.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.
A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.
B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.
D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.
Correct Answer is B
Explanation
B. A client who is postoperative with shallow respirations at a rate of 9/min is likely not adequately eliminating carbon dioxide from their body due to hypoventilation. This retention of carbon dioxide can lead to an increase in the partial pressure of CO2 in the blood, causing an acidotic state.
A. Metabolic acidosis results from an accumulation of acids in the body or a loss of bicarbonate. Hypoventilation leading to respiratory acidosis does not directly cause metabolic acidosis.
C. Respiratory alkalosis occurs when there is excessive elimination of CO2 from the body, leading to decreased arterial carbon dioxide levels (hypocapnia) and an increase in pH. Shallow respirations and decreased respiratory rate are more consistent with hypoventilation and respiratory acidosis rather than hyperventilation and respiratory alkalosis.
D. Metabolic alkalosis results from excessive loss of acids or increased bicarbonate levels in the body. Hypoventilation leading to respiratory acidosis does not directly cause metabolic alkalosis.
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