The nurse suctions the client with pneumonia. Which client assessment data requires the nurse to discontinue suctioning?
1. Pulmonary infiltrates are on chest x-ray.
2. Client coughing clear, watery secretions.
3. Oxygen saturation falls from 97% to 92%.
4. Heart rate decreases from 84 to 59 beats/min.
4
4. Bradycardia during suctioning is consistent with clinical indicators of vasovagal stimulation and requires the nurse to discontinue the suctioning. The nurse applies oxygen quickly and hyperoxygenates as needed. The nurse continues to monitor the heart rate and checks the client's blood pressure, level of consciousness, SaO2, and respiratory rate for an assessment. If the heart rate does not recover quickly to base-line levels, the nurse should collaborate with the provider and prepare emergency drugs and equipment.
1. The nurse expects to view pulmonary infiltrates on the chest x-ray as evidence of the lung infection.
2. The nurse expects thin, clear secretions during suctioning and the secretions indi-cate effective coughing.
3. An SaO2 of 92% from 97% is a transient drop in the oxygen saturation from hy-poxemia induced from suctioning.
You might also like to view...
Milo, a 19-year-old, lives in an inner-city apartment complex. One late night he was walking home after hanging out with his friends
Before he knew what was happening, someone jumped Milo from behind and tried to get his wallet. A fight broke out, and the thief stabbed Milo in the abdomen before taking off. When the paramedics arrived, Milo was pale, sweating, and rolling restlessly on the ground. His pulse was 94 beats/minute and his blood pressure 115/82 mm Hg. He was rushed to the hospital where his treatment began immediately. Why is Milo presenting with pallor, diaphoresis, and restlessness? In spite of his blood loss, Milo's blood pressure was only slightly affected when the paramedics first found him. Describe how cardiovascular compensatory mechanisms serve to maintain homeostasis as long as possible in the early stages of shock. How does ADH contribute to compensation? What are the disadvantages of prolonged vasoconstriction in hypovolemic shock? If Milo's respirations were to become progressively deeper and more rapid, what physiological changes in the body would that indicate?
A nurse who has practiced on an orthopedic unit for 10 years unexpectedly becomes pregnant
At delivery the physician informs the mother, "Your baby has Alport syndrome, but then I don't have to explain what that means with your medical background." The mother is unfamiliar with this disease and withdraws as a coping mechanism. Which nursing theory would provide a framework to guide nursing care for this mother? a. Mishel's uncertainty of illness b. Orem's self-care deficit model c. Nightingale's canons of nursing d. Levine's conservation model
A charge nurse is providing education to coworkers on state nursing associations. The charge nurse judges that the teaching has been effective when a coworker states:
a. "These professional associations address nursing practice.". b. "These professional associations do noth-ing to support nursing.". c. "These professional associations protect the rights of physicians.". d. "These professional associations are ma-naged by hospital administrators.".
A 78-year-old home health client has admitted to his nurse that his level of sexual activity with his wife has declined in recent months and become wholly absent over the past several weeks
The client has implied that this is due to a lack of performance, rather than lack of desire, on his part. What assessment should the nurse prioritize in light of this revelation? A) Client's medication regimen B) Client's musculoskeletal system and active range of motion C) Client's cognitive status and level of consciousness D) Client's cardiovascular status