Nokea
The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?
Correct Answer: D
Rationale: Restlessness and tachycardia during suctioning suggest hypoxia or distress; discontinuing suctioning and monitoring vital signs (D) is the priority to stabilize the client. Notifying the provider (A) or respiratory (B) delays immediate action. Hyperoxygenating and resuctioning (C) risks worsening hypoxia. D is correct. Rationale: Stopping suctioning halts oxygen depletion, allowing recovery, while monitoring guides further intervention, a standard response per airway management protocols. This prevents complications like arrhythmias or desaturation, prioritizing patient safety over premature escalation or repeated procedures in an unstable state.