A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?
Sore throat
SaO, 92%
Stridor
Rhonchi
The Correct Answer is C
C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.
A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","G"]
Explanation
The blood pressure is elevated. This may indicate a compensatory mechanism to try increases myocardial perfusion. However, this increases the oxygen demand worsening the condition.
Pain level of 7 indicates severe pain typical of acute coronary syndrome. The pain may worsen the extent of ischemia and hence morphine should be administered immediately
ECG findings are typical for myocardial infarction and intervention is key to prevent further myocardial damage.
Troponin levels are elevated due to damage of myocardium
Blood sugar level, bowel sounds and lung sounds are normal and therefore, requires no intervention.
Correct Answer is B
Explanation
B. Proteinuria is a hallmark finding in nephrotic syndrome. Proteinuria refers to the presence of excess protein, particularly albumin, in the urine. It occurs due to increased permeability of the glomerular filtration barrier, allowing proteins to leak into the urine rather than being retained in the bloodstream.
A. Individuals with nephrotic syndrome may be at an increased risk of thrombosis (formation of blood clots) due to loss of anticoagulant proteins such as antithrombin III in the urine.
C. Nephrotic syndrome is characterized by hypoalbuminemia, which is a decreased level of albumin in the bloodstream. The loss of albumin in the urine leads to decreased serum albumin levels, contributing to edema formation and other complications associated with nephrotic syndrome.
D. Decreased serum lipid levels is not a typical finding in nephrotic syndrome. In fact, individuals with nephrotic syndrome often have dyslipidemia, characterized by elevated serum lipid levels, including cholesterol and triglycerides.
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