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. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.
Correct Answer is ["A","D"]
Explanation
A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.
B. Attending a course does not confirm comprehension or skill.
C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.
D. Listing healthy food choices indicates understanding of dietary education.
E. Nodding does not confirm learning; it may only indicate acknowledgment.