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 B
Explanation
B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.
Correct Answer is D
Explanation
D. Hot flashes are a common symptom following a bilateral orchiectomy due to the sudden decrease in testosterone levels. Hot flashes are characterized by sudden feelings of warmth, flushing, and sweating, often accompanied by a rapid heartbeat. These symptoms can be bothersome but are typically temporary and can be managed with lifestyle modifications and medications if necessary.
A. Hypoglycemia is not typically associated with a bilateral orchiectomy.
B. Testosterone, primarily produced by the testicles, plays a significant role in promoting muscle mass and strength. Removal of the testicles results in a significant decrease in testosterone production, which may lead to a gradual decline in muscle mass and strength over time.
C. Testosterone is a key hormone involved in regulating libido in both men and women. Removal of the testicles leads to a significant decrease in testosterone levels, which may result in a decrease in libido rather than an increase.
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