During tracheal suctioning, the nurse notes that the client' heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take?
1. Immediately discontinue suctioning.
2. Prepare to resuscitate the client.
3. Continue to suction until the airway is clear.
4. Complete the suction episode as quickly as possible.
Correct Answer: 4
Rationale 1: There is no need to immediately discontinue suctioning.
Rationale 2: There is no need to prepare to resuscitate the client.
Rationale 3: The client will likely not tolerate continuing the suction episode until the airway is clear.
Rationale 4: An increase in heart rate from 80 to 100 is not an unusual finding during suctioning, but does indicate increased stress on the client. The nurse should complete the suctioning episode as quickly as possible.
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