Nursing Prioritization Delegation Assignment Q 81
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 registered nurse 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 101.4ºF (38.6ºC)
Correct Answer: D. Tympanic temperature of 101.4ºF (38.6ºC)
Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
Option A: The normal range used in an adult is between 60 to 100 beats/minute with rates above 100 beats/minute and rates below 60 beats per minute, referred to as tachycardia and bradycardia, respectively. The rate of the pulse is significant to measure for assessing the physiological and pathological processes affecting the body.
Option B: The normal breathing rate is about 12 to 20 breaths per minute in an average adult. Tachypnea is described as a respiratory rate of more than 20 breaths per minute that could occur in physiological conditions like exercise, emotional changes, or pregnancy. Pathological conditions like pain, pneumonia, pulmonary embolism, asthma, foreign body aspiration, anxiety conditions, sepsis, carbon monoxide poisoning, and diabetic ketoacidosis can also present with tachypnea.
Option C: Blood pressure is an essential vital sign to comprehend the hemodynamic condition of the patient. Unfortunately, though, there are a lot of inter-person variabilities when measuring it. All healthcare providers should be aware of making sure all the essential prerequisites are met before checking the blood pressure of the patient.