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 Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. There is a potential risk of lactic acidosis when metformin is used in conjunction with contrast material, particularly in patients with underlying renal impairment. Contrast-induced nephropathy can exacerbate renal dysfunction, leading to increased levels of metformin and potentially increasing the risk of lactic acidosis. Therefore, metformin use before or after contrast administration should be carefully monitored, and in some cases, temporarily discontinued to reduce the risk of lactic acidosis.
A Atorvastatin is a statin medication commonly used to lower cholesterol levels. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).
C Carvedilol is a beta-blocker medication used to treat high blood pressure and heart failure. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast-induced nephropathy (CIN).
D Nitroglycerin is a medication commonly used to relieve chest pain (angina) in patients with coronary artery disease. It does not have a direct interaction with contrast material used in cardiac catheterization. Therefore, it does not place the client at risk for acute kidney injury related to contrast- induced nephropathy (CIN).
Correct Answer is A
Explanation
A. Positive end-expiratory pressure (PEEP) is applied during mechanical ventilation to prevent alveolar collapse at the end of expiration. It helps maintain the patency of the alveoli, improving oxygenation and preventing atelectasis.
B. While PEEP can improve oxygenation by recruiting collapsed alveoli and increasing functional residual capacity, it does not directly affect the concentration of oxygen delivered by the ventilator. Oxygen concentration is adjusted separately from PEEP settings.
C. PEEP is applied at the end of expiration to maintain positive pressure in the airways and alveoli, preventing them from collapsing. It does not directly affect the delivery of air during inhalation.
D. PEEP can help prevent lung damage by maintaining alveolar recruitment and reducing the risk of atelectasis and barotrauma. However, it is not the sole factor in preventing lung damage, and other ventilator settings and strategies also play a role in protecting the lungs.
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