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 E
Explanation
A. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.
Correct Answer is B
Explanation
A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.