A nurse is preparing to suction a patient. The pulse is 65 and ...

[Zulu123]

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94. Which finding will cause the nurse to stop suctioning?
 
  a. Pulse 75
  b. Pulse 80
  c. Oxygen saturation 91
  d. Oxygen saturation 88

Question 2

A nurse is caring for a group of patients. Which patient should the nurse see first?
 
  a. A patient with hypercapnia wearing an oxygen mask
  b. A patient with a chest tube ambulating with the chest tube unclamped
  c. A patient with thick secretions being tracheal suctioned first and then orally
  d. A patient with a new tracheostomy and tracheostomy obturator at bedside

[ntsoane kedibone]

Answer to Question 1

ANS: D
Stop when oxygen saturation is 88. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90 or 5 from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91 is not 5 from baseline or below 90.

Answer to Question 2

ANS: A
The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged.

[Zulu123]

Excellent

[ryansturges]

Gracias!