HESI Registered Nurse EXIT Practice Exam

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Which client assessment finding on a volume-cycled ventilator indicates a need for suctioning?

Drowsiness
Complaint of nausea
Restlessness
Pulse rate of 92

The correct answer is: Restlessness

Restlessness in a client on a volume-cycled ventilator is a significant assessment finding that may indicate the need for suctioning. When a patient requires suctioning, it is often due to copious secretions or mucus obstruction in the airway, which can lead to inadequate ventilation and hypoxia. This causes discomfort, distress, and agitation, manifesting as restlessness. In patients receiving ventilatory support, restlessness can signal that the body is attempting to communicate an obstruction or difficulty in breathing, prompting the healthcare provider to assess for the presence of secretions. Addressing this promptly through suctioning can restore the patency of the airway, improve oxygenation, and enhance the patient's comfort. While drowsiness, nausea, and a pulse rate of 92 may be notable, they are not direct indicators of airway obstruction or the immediate need for suctioning. Drowsiness might be attributed to sedatives or sleepiness, nausea could stem from various causes unrelated to airway patency, and a pulse rate of 92 falls within a normal range for many patients. Therefore, the most relevant and indicative sign for needing suctioning in this context is restlessness.