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After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

a) Heart rate of 98 beats/min

b) Respiratory rate of 24 breaths/min

c) Blood pressure of 168/90 mm Hg

d) Tympanic temperature of 101.4 F (38.6 C)

User Starlene
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Final answer:

The vital sign value that the nursing assistant should report immediately is a blood pressure of 168/90 mm Hg, as it is significantly higher than the normal range and could signal a serious health issue.

Step-by-step explanation:

In the post-suction assessment of an intubated patient, the nursing assistant should prioritize reporting a blood pressure of 168/90 mm Hg to the registered nurse immediately. This reading significantly exceeds the normal range of 90/60 to 120/80 mm Hg and may signal a potentially serious condition, possibly related to the suctioning procedure. While a heart rate of 98 beats/min and a respiratory rate of 24 breaths/min are slightly elevated, they can be attributed to stress or the suctioning process.

A tympanic temperature of 101.4 F indicates a fever but may not demand urgent attention unless accompanied by other concerning symptoms. In this context, the critical blood pressure reading takes precedence, prompting swift reporting and intervention to address potential complications or adverse effects related to the patient's cardiovascular health.

User Morfioce
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