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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In the initial 24 hours after burn injury, fluid resuscitation is a critical priority in the management of burn patients. Burn injuries can lead to significant fluid loss, both locally at the burn site and systemically due to increased capillary permeability. Fluid resuscitation aims to restore and maintain adequate intravascular volume, ensuring sufficient tissue perfusion and organ function.
The Parkland Formula is commonly used to guide fluid resuscitation in burn patients. It involves calculating the total volume of fluid needed in the first 24 hours, with a portion given in the initial hours after injury and the remainder given over the remaining hours.
A. Sterile dressing changes (option A) are incorrect because they are important in wound care management for burn patients to prevent infection. However, fluid resuscitation takes precedence within the first 24 hours.
B. Emotional support (option B) is incorrect because it is an essential aspect of burn care, as burn injuries can have a significant psychological impact. While emotional support is crucial for the patient's overall well-being, it may not be the highest priority within the first 24 hours compared to addressing the physiological needs of fluid resuscitation.
D. Range-of-motion exercises (option D) are incorrect because they are important for preventing contractures and maintaining joint mobility in burn patients. However, they are typically initiated after the initial fluid resuscitation phase and wound stabilization.
Therefore, the priority the nurse anticipates within the first 24 hours for a 31-year-old male patient with burn injuries is fluid resuscitation.
Correct Answer is B
Explanation
Disseminated Intravascular Coagulation (DIC) is a condition characterized by widespread activation of the coagulation system, leading to both excessive clot formation and consumption of clotting factors and platelets. This process can result in both bleeding and thrombosis.
The manifestations mentioned in option B are commonly seen in DIC:
Decreased platelet counts: DIC leads to platelet consumption and destruction, resulting in low platelet counts (thrombocytopenia).
Increased D-dimer: D-dimer is a fibrin degradation product, and its levels are increased DIC due to the breakdown of fibrin clots.
Increased prothrombin time (PT): DIC can lead to the depletion of clotting factors, resulting in prolonged prothrombin time, indicating impaired coagulation.
The other options mentioned do not represent the typical clinical manifestations of DIC:
A. Decreased hematocrit, increased platelet counts, and increased D-dimer in (option A) are incorrect because While platelet counts and D-dimer are increased in DIC, decreased hematocrit is not a characteristic finding.
C. Decreased Antithrombin III, increased platelet counts, and increased fibrinogen in (option C) is incorrect because: Decreased Antithrombin III can be seen in DIC, but increased platelet counts and fibrinogen levels are not specific to DIC.
D. Decreased D-dimer, increased platelet counts, and increased hemoglobin in (option D) is incorrect because Decreased D-dimer and increased hemoglobin are not typical findings in DIC, while increased platelet counts can be seen in some cases.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today