The client has supplemental oxygen in place and requires ...

[joe]

The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximum oxygenation, an appropriate action by the nurse is to:
 
  1. Suction continuously for 30-second intervals
  2. Replace the oxygen and allow rest in between suctioning passes
  3. Increase the amount of suction pressure to 200 mm Hg
  4. Complete a number of suctioning passes until the catheter comes back clear

Question 2

The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. Upon en-tering the room, the nurse expects to find the client:
 
  1. Extremely fatigued
  2. Complaining of chest pain
  3. Experiencing a fluttering sensation in the chest
  4. Having no clinical signs based on the assessment

[briezy]

Answer to Question 1

ANS: 2
To promote maximum oxygenation, the nurse should replace the oxygen and allow rest in be-tween suctioning passes. Suctioning should be intermittent for up to 10 to 15 seconds. Wall suc-tion is set at 80 to 120 mm Hg; portable suction is set at 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk for trauma to mucosa and can induce greater hypoxia. The number of suctioning passes is determined by client assessment and need. Repeated passes can remove oxygen and may induce laryngospasm. The client is not suctioned until the catheter comes back clear.

Answer to Question 2

ANS: 4
The nurse would expect to find the client experiencing a sinus dysrhythmia at a rate of 82 beats per minute to have no clinical symptoms. The client with atrial fibrillation may complain of fa-tigue. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain. The client with atrial fibrillation may complain of a fluttering sensation in the chest.

[joe]

TYSM

[kusterl]

Excellent