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.
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Related Questions
Correct Answer is C
Explanation
C. Mannitol is a osmotic diuretic that is commonly used in the management of increased intracranial pressure (ICP) following a head injury. It works by drawing fluid out of brain tissue and into the bloodstream, thereby reducing cerebral edema and lowering ICP.
A. Chlorpromazine is an antipsychotic medication that does not have direct effects on reducing ICP and is not commonly used in this clinical scenario.
B. Dobutamine is a medication primarily used for increasing cardiac output in patients with heart failure or shock.
D. Propranolol is a beta-blocker medication commonly used to treat conditions such as hypertension, angina, and certain cardiac arrhythmias.
Correct Answer is A
Explanation
A. Turning the client on their side helps prevent aspiration (inhaling fluid or vomit into the lungs) and promotes drainage of oral secretions, reducing the risk of airway obstruction during the seizure.
B. While assessing neurological status is important, it should be done after ensuring the client's safety during the seizure. This can be done after the seizure has stopped.
C. While obtaining vital signs is important for assessing the client's overall condition, it is not the immediate priority during an active seizure. Vital signs can be assessed once the seizure has stopped and the client's safety has been ensured.
D. Notifying the rapid response team may be necessary if the seizure persists beyond a certain duration (status epilepticus) or if there are complications. However, the first action should be to ensure the client's immediate safety by turning them onto their side to prevent aspiration.
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