JIPMER Pondicherry NO - 2022
Medical Surgical Nursing
Hard
While giving ET tube suctioning, the patient suddenly goes on tachycardia. What will the nurse do?
Appeared in: JIPMER Pondicherry NO - 2022
Explanation
- Tachycardia (a heart rate over 100 bpm) during suctioning is a critical sign of hypoxemia (low oxygen).
- The body's compensatory response to low oxygen is to increase the heart rate to circulate the remaining oxygenated blood faster.
- The priority nursing action is to treat the underlying cause by immediately stopping the procedure that is removing oxygen and administering supplemental oxygen.
- This is a life-saving intervention that falls within the nurse's scope of practice and should be performed before any other action.
Why Other Options Were Wrong
- Option B: Continuing to suction while the patient is tachycardic will worsen hypoxemia and can lead to more severe complications like dangerous arrhythmias or cardiac arrest.
- Option C: Increasing suction pressure does not address the cause of tachycardia (hypoxemia) and increases the risk of damaging the tracheal mucosa, which can cause bleeding and swelling.
- Option D: This action delays critical, immediate intervention. The nurse must first stabilize the patient using the ABCs (Airway, Breathing, Circulation) framework. Informing the doctor is a secondary step after initial life-saving measures are taken.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Management of complications during endotracheal suctioning to guide bedside assessment, documentation, and the next nursing action.
- Recognizing and responding to complications during routine procedures like suctioning is a critical nursing responsibility. Tachycardia is an early warning sign of distress that must be acted upon immediately.
- This scenario highlights the importance of the 'Assess, Intervene, Re-assess' model in nursing. The nurse assesses the patient, notes the tachycardia, intervenes by stopping suction and giving oxygen, and then re-assesses for improvement.
- Patient safety is paramount. Adhering to established guidelines for suctioning (e.g., time limits, pressure settings, pre-oxygenation) minimizes the risk of adverse events.
How to Approach the Question
- First, identify the clinical context: a patient with an endotracheal tube is undergoing suctioning.
- Next, recognize the abnormal finding: the patient 'suddenly goes on tachycardia'. This is the key problem.
- Analyze the cause. In this specific context, suctioning removes air and oxygen, so tachycardia is a classic sign of hypoxemia (lack of oxygen).
- Apply the ABCs (Airway, Breathing, Circulation) priority framework. The problem is related to 'Breathing' and oxygen supply.
- Evaluate the options based on which one most directly and immediately addresses the ABC problem. Stopping the cause of oxygen loss (suctioning) and providing oxygen is the most immediate and effective intervention.
- Rule out other options. Continuing the procedure is harmful. Increasing pressure is irrelevant and dangerous. Informing the doctor delays essential, immediate care.
Concept Tested & Keywords
- Concept Tested: Management of complications during endotracheal suctioning
- Stem keywords: ET tube suctioning, tachycardia, nurse
- Lead-in keywords: What will the nurse do?
- Clinical cues: Sudden onset of tachycardia during a medical procedure
Question ID
QgNf9lTvbJkq30yvOAnna8
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 16-18
Practise the full JIPMER Pondicherry NO - 2022
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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