A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?
Pulse 60
Pulse 90
Oxygen saturation of 92%
Oxygen saturation 89%
Blood pressure 130/80
The Correct Answer is D
A. A pulse of 60 is low but does not necessarily indicate a need to stop suctioning if the patient remains stable otherwise.
B. A pulse of 90 is within normal limits and does not require stopping suctioning.
C. An oxygen saturation of 92% is slightly low but still acceptable; suctioning can continue if the client is stable.
D. An oxygen saturation of 89% is below the acceptable threshold and indicates hypoxia, prompting the nurse to stop suctioning immediately to avoid further compromising the client's respiratory status.
E. A blood pressure of 130/80 is within normal limits and does not warrant cessation of suctioning.
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Correct Answer is ["A","B"]
Explanation
A. S4 is often considered a normal finding in older adults due to decreased ventricular compliance.
B. While it can be non-pathologic, it is more commonly associated with underlying conditions such as hypertension or heart failure.
C. The statement about being heard just after S2 is incorrect; S4 can be heard in various populations, particularly older adults.
D. An S4 sound is associated with a stiff or hypertrophied ventricle, not a dilated ventricle.
E. An S4 sound is not typically an expected finding in children; it is more common in older adults.
Correct Answer is A
Explanation
A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.
B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.
C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.
D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.
E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.