1. A nurse is trying to determine whether or not a patient's
artificial airway should be suctioned. Which of the following is
not an indication for suctioning? Correct Answers Pulse
oximetry of 89%
A patient has clear oral secretions that are extremely copious
and thick. What would be an
appropriate response by the nurse? Correct Answers
Oropharyngeal suction
A patient with a weak cough has secretions in the lower airway.
What would be an
appropriate response by the nurse? Correct Answers
Nasotracheal suctioning
After the NAP performs routine vital signs on the patient, the
NAP reports to the nurse that the aptient is restless, and it
sounds like the patient is gurgling. Vital sign reading indicate a
pulse of 72, respiratory rate of 20 breaths per minute, and a
pulse oximetry of 89%. What is the most appropriate action at
this time? Correct Answers Suction the patient's airway.
Choose the symptoms that indicate the need to suction a
tracheostomy tube. (Select all that
apply. Correct Answers Sonorous wheezing
Gurgling
Restless/anxious
, Cyanosis
Mucus draining from the tracheostomy tube
Pulse oximetry value less that 90%
During clinical postconference, a student nurse is telling the
group about his day in the
intensive care unit (ICU). He says that he was performing inline
suctioning when the patient's
pulse oximetry reading changed from 96% to 90% and the
patient's heart rate went from 86
to 62 beats per minute. What action should the student nurse
report having taken? Correct Answers Stop suctioning and
administer oxygen
For the patient who extubated himself, what priority action
should the nurse take? Correct Answers Determine whether
the patient is breathing spontaneously.
he nurse is performing closed inline suctioning. Preprocedure
assessment indicated
crackles and wheezes bilaterally, pulse rate 72, respiratory rate
20 breaths per minute, and
pulse oximetry 89%. Which of the following indicates the nurse
should stop suctioning and
administer oxygen? Correct Answers The patient's pulse
increases to 114 beats per minute.