Which assessment information obtained by the nurse when caring for a COPD patient receiving mechanical ventilation indicates the need for suctioning?
The pulse oximeter shows a Sp02 of 90%.
The patient has not been suctioned for the last 6 hours.
The respiratory rate is 32 breaths/min.
The lungs have occasional audible expiratory wheezes.
The Correct Answer is C
In a patient receiving mechanical ventilation, a high respiratory rate can indicate increased work of breathing and potential airway obstruction. COPD patients, in particular, may have excessive mucus production and airway inflammation, leading to mucus plugging and compromised airway clearance. Suctioning may be necessary to remove excessive secretions and maintain a patent airway.
A. The pulse oximeter shows a SpO2 of 90% in (option A) is incorrect because While a SpO2 of 90% is suboptimal and may require intervention, it does not specifically indicate the need for suctioning. Other interventions, such as adjusting oxygen delivery or ventilation settings, may be more appropriate.
B. The patient has not been suctioned for the last 6 hours in (option B) is incorrect because The duration since the last suctioning episode alone does not necessarily indicate the need for suctioning. The need for suctioning should be based on the patient's clinical presentation, such as signs of airway obstruction or excessive secretions.
D. The lungs have occasional audible expiratory wheezes in (option D) which is incorrect because Occasional audible expiratory wheezes may be common in patients with COPD and may not specifically indicate the need for suctioning. Wheezing is more commonly associated with narrowing of the airways, and suctioning is typically performed to clear secretions or maintain airway patency.
C. Therefore, in a COPD patient receiving mechanical ventilation, a high respiratory rate (C) is the assessment information that would indicate the need for suctioning to help remove excessive secretions and ensure a patent airway
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. In the context of shock, a MAP of 50 mm Hg is considered low and indicates inadequate tissue perfusion.
To improve tissue perfusion and restore blood pressure, the nurse would anticipate administering large volumes of intravenous fluids, such as Lactated Ringers (LR). Fluid resuscitation aims to increase intravascular volume and improve cardiac output, ultimately leading to improved tissue perfusion.
B. Cardiac Output (CO) is 4 L/min in (option A) is incorrect because Cardiac output represents the volume of blood pumped by the heart per minute. While a low cardiac output may require intervention, it does not specifically indicate the need for large volumes of fluid administration.
C. Stroke volume is 70 ml/beat in (option C) is incorrect because Stroke volume refers to the volume of blood ejected by the heart with each contraction. While stroke volume can be an important determinant of cardiac output, it alone does not indicate the need for large fluid volumes.
D. The heart rate is 80 bpm in (option D) is incorrect because: Heart rate is the number of heartbeats per minute. While the heart rate can impact cardiac output, it does not provide direct information about fluid resuscitation needs.
Correct Answer is C
Explanation
Hypovolemic shock is a life-threatening condition resulting from severe blood or fluid loss. The patient in this scenario exhibits signs of hypovolemic shock, such as low blood pressure, tachycardia, cool and clammy skin, and decreased urine output.
When assessing the prescription options, the nurse should consider the appropriateness of each intervention for hypovolemic shock. Plasmanate is a type of plasma protein fraction that is used for volume expansion in certain situations. However, in hypovolemic shock, the primary intervention is to restore intravascular volume promptly. Plasmanate alone may not be sufficient for rapid-volume resuscitation.
In hypovolemic shock, the initial management typically involves the administration of crystalloid solutions, such as Lactated Ringers or Normal Saline, to restore intravascular volume. Therefore, the prescription of Plasmanate as the primary intervention raises concerns and should be questioned by the nurse.
A. Dopamine (Intropin) 12 mcg/min in (option A) is incorrect because: Dopamine is a vasopressor medication used to increase blood pressure and cardiac output. It is a suitable option for hypovolemic shock to support blood pressure and tissue perfusion.
B. Dobutamine (Dobutrex) 5 mcg/kg/min in (option B) is incorrect because: Dobutamine is an inotropic medication that helps improve cardiac contractility and cardiac output. It can be beneficial in cases of hypovolemic shock with signs of poor cardiac function.
D. Bumetanide (Bumex) 1 mg IV in (option D) is incorrect because: Bumetanide is a loop diuretic used to promote diuresis. However, in the context of hypovolemic shock, diuretics are generally not the first-line treatment as they can further reduce intravascular volume and worsen the patient's condition.
It is essential for the nurse to consult with the healthcare provider regarding the prescription order of Plasmanate and consider alternative interventions for rapid volume resuscitation in hypovolemic shock.
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