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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A. Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.

A. Chloride level B. Creatinine kinase C. Uric acid D. Intrinsic factor

Correct Answer is C

Explanation

C. Uric acid is the end product of purine metabolism, and elevated levels of uric acid in the blood can predispose individuals to gout. In acute gout, there is often a marked increase in serum uric acid levels due to the release of uric acid from the breakdown of purines during the inflammatory process.
A. Chloride level is not directly associated with acute gout.
B. Creatinine kinase (CK) is an enzyme found in various tissues, including muscle tissue. Elevated CK levels are associated with muscle damage or injury, such as in cases of muscle trauma, myocardial infarction, or rhabdomyolysis.
D. Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach that is necessary for the absorption of vitamin B12 in the small intestine.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results?

Correct Answer is C

Explanation

The nurse is reviewing the client's medical record. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect?

A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?

A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take?