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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Cheyne-Stokes respirations involve a cyclical pattern of breathing characterized by gradual increase and decrease in the depth and rate of respirations, with periods of hyperventilation alternating with periods of apnea. It is commonly seen in patients with neurological disorders, heart failure, or drug overdose.
A. Apneustic respirations are characterized by prolonged inspiratory gasps followed by a brief pause and insufficient expiration. This pattern is often associated with damage to the pons in the brainstem.
C. Stridor is a high-pitched, noisy respiratory sound caused by turbulent airflow through partially obstructed airways. It is typically heard during inspiration and is often associated with upper airway obstruction, such as in cases of croup or epiglottitis.
D. Kussmaul respirations are deep, rapid, and labored breathing patterns often seen in patients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
Correct Answer is B
Explanation
B. Tachycardia is a compensatory mechanism aimed at increasing cardiac output and maintaining tissue perfusion. In response to decreased perfusion, the body increases heart rate to improve circulation and oxygen delivery to tissues.
A. Hypokalemia, or low potassium levels, is not typically associated with the compensatory stage of shock. Instead, electrolyte imbalances may develop later in the progression of shock due to tissue hypoperfusion and metabolic disturbances.
C. Mottled skin, characterized by patchy discoloration due to uneven blood flow, is more commonly seen in the progressive or irreversible stages of shock. It indicates significant tissue hypoperfusion and impaired microcirculation, rather than the compensatory stage
D. This blood pressure reading is within the normal range and may be maintained during the compensatory stage of shock. Initially, blood pressure may be maintained or only slightly decreased due to compensatory mechanisms such as vasoconstriction. However, blood pressure can decrease further as shock progresses beyond the compensatory stage.
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