Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
a. The patient's oxygen saturation is 93%.
b. The patient was last suctioned 6 hours ago.
c. The patient's respiratory rate is 32 breaths/minute.
d. The patient has occasional audible expiratory wheezes.
ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
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