NCLEX-PN

Category - Reduction of Risk

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A nurse is suctioning the secretions in a client’s endotracheal tube. During the procedure, the client’s heart rate begins to drop. Which of the following is the first action of the nurse?

Assist the client in semi-Fowler’s position
Continue suctioning; this is an expected outcome
Reoxygenate the client
Stop suctioning

Explanation

Answer: D - During suctioning, ventilations cease. The first action of the nurse is to stop suctioning, and then reoxygenate the client. The other options are not appropriate.

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