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%.

Answer and Explanation

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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Correct Answer is B

Explanation

B. Endotracheal intubation and positive pressure ventilation are indicated in patients with respiratory failure who are unable to maintain adequate oxygenation or ventilation with non-invasive interventions. Intubation allows for the delivery of positive pressure ventilation, oxygenation, and airway protection. It also facilitates the clearance of secretions and administration of medications. Given the patient's severe hypoxemia, impending respiratory distress, and deteriorating condition, endotracheal intubation and positive pressure ventilation are the most appropriate interventions to ensure adequate oxygenation and prevent further deterioration.

A. CPAP is a non-invasive ventilation modality that provides a continuous positive pressure to the airways throughout the respiratory cycle. While CPAP may be beneficial in certain cases of respiratory failure, it may not be sufficient for a patient with severe hypoxemia (SpO2 of 80%) and impending respiratory distress. CPAP is typically indicated for patients with conditions such as obstructive sleep apnea or mild to moderate respiratory failure.

C. Mini-tracheostomy may be considered in certain cases of upper airway obstruction or inadequate airway clearance. However, in this scenario, the patient's hypoxemia is likely due to severe respiratory failure rather than upper airway obstruction. While suctioning may be necessary to clear secretions, it does not address the underlying cause of hypoxemia or provide ventilatory support.

D. While administration of supplemental oxygen is important in the management of hypoxemia, a non- rebreather mask may not be sufficient for a patient with severe hypoxemia and impending respiratory distress. Non-rebreather masks can deliver high concentrations of oxygen but may not provide adequate positive pressure support or airway protection. In this case, endotracheal intubation and positive pressure ventilation are more appropriate to ensure adequate oxygenation and ventilation.

A. Insert a nasogastric (NG) tube. B. Type and cross-match for 2 units of packed RBCs. C. Administer broad-spectrum antibiotics. D. Measure lactate level. E. Rapidly administer 30 ml/kg of normal saline. F. Obtain blood cultures. G. Obtain a urine specimen. H. Obtain a wound culture.

Correct Answer is ["C","D","E","F"]

Explanation

A. Administering antibiotics helps target the suspected infection and prevent its spread. Broad-spectrum antibiotics are typically initiated until the specific pathogen is identified through cultures. This action should be completed as soon as possible within the first hour.

D. Lactate measurement is important in assessing tissue perfusion and the severity of sepsis. Elevated lactate levels indicate tissue hypoperfusion and can help identify patients at higher risk of mortality. Monitoring lactate levels guides resuscitation efforts and helps in assessing the response to treatment.

E. Fluid resuscitation is a cornerstone in the management of sepsis. Administering a large volume of intravenous fluids helps restore intravascular volume, improve tissue perfusion, and prevent further organ dysfunction. The recommended initial fluid bolus is 30 ml/kg of crystalloid solution, such as normal saline, administered rapidly within the first few hours of recognition of sepsis.

F. Blood cultures help identify the causative organism(s) responsible for the sepsis. This information is crucial for guiding antibiotic therapy, especially in cases of severe sepsis or septic shock. Blood cultures should be obtained before initiating antibiotic therapy to maximize their sensitivity and specificity.

B. Type and cross-match for packed red blood cells (PRBCs) are indicated in situations where blood transfusion may be required, such as severe anemia or active bleeding. While sepsis can lead to various complications, such as disseminated intravascular coagulation (DIC), the priority in the first hour is resuscitation and antibiotic administration.

G. Obtaining a urine specimen may be indicated to assess for urinary tract infection (UTI), which can be a potential source of sepsis. However, in the initial management of sepsis, obtaining blood cultures (option F) takes precedence as blood cultures provide more critical information for guiding antibiotic therapy.

H. Obtaining a wound culture may help identify the specific pathogens present in the wound and guide antibiotic therapy if the wound is suspected to be the source of sepsis. However, in the first hour of managing sepsis, the priority is to initiate broad-spectrum antibiotics and obtain blood cultures, as these interventions are more urgent in preventing further complications from sepsis.

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Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["C","D","E","F"]

Explanation

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