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
Explanation
A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.
Correct Answer is B
Explanation
A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.