Question

A nurse checks a client who was placed on a volume-cycled ventilator. Which finding indicates that the nurse needs to suction the client?

A. Report of nausea
B. Heart rate 82 BPM
C. Drowsiness
D. Restlessness

Answer 1

Restlessness is an indication that a client on a ventilator may need to be suctioned, as it suggests potential airflow obstruction by secretions needing clearance to improve ventilation and oxygenation.

Step-by-step explanation:

When assessing if a client on a ventilator needs to be suctioned, various clinical indicators can guide a nurse's decision. Among the choices provided, restlessness is a critical sign that can suggest the patient's airway may have secretions obstructing airflow, requiring suctioning. Restlessness may indicate hypoxia, where the body isn't receiving enough oxygen, possibly due to mucus or fluid build-up that can block the airway and interfere with effective ventilation.

While a heart rate of 82 BPM does not necessarily indicate the need for suctioning, signs like an elevated heart rate, profuse sweating, difficulty sleeping, or weight loss may indicate a systemic response to stress or infection and should not be ignored. Reports of nausea or drowsiness, in isolation, are not direct indicators of the need for suction. However, they could be part of a broader clinical picture requiring a comprehensive assessment.