A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

Copious oral secretions

Stridor

Hoarseness

Sore throat

Answer and Explanation

The Correct Answer is B

A. Copious oral secretions can be common after extubation and can be managed with suctioning.
B. It indicates possible airway obstruction or swelling and requires immediate evaluation and intervention.
C. Hoarseness is a common, usually temporary, side effect after extubation.
D. Sore throat is also common and typically resolves without intervention.

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Correct Answer is ["C","E","G"]

Explanation

A. Temperature (96.9°F / 36°C) – Mild hypothermia, but not immediately life-threatening; does not require immediate follow-up.

B. Bilirubin (6.2 mg/dL) – Significantly elevated and indicates worsening liver function, but this is expected in cirrhosis and does not require immediate action unless accompanied by signs of acute liver failure.

C. Blood pressure (82/58 mm Hg) – Requires immediate follow-up as this indicates hypotension, which can be due to complications like sepsis, hepatorenal syndrome, or third-spacing from ascites.

D. Scattered ecchymosis – Indicates coagulopathy, which is common in cirrhosis; important but not immediately life-threatening unless active bleeding is present.

E. Ammonia level (78 mcg/dL) – Requires immediate follow-up. This is markedly elevated and correlates with hepatic encephalopathy, especially in the presence of neurologic symptoms.

F. Abdominal girth increase – Suggests worsening ascites; needs management but not as urgent as hemodynamic instability or encephalopathy signs.

G. Asterixis (flapping tremor) – Requires immediate follow-up. This is a classic sign of hepatic encephalopathy, which can progress rapidly and lead to coma if untreated.

A. Hold administration of analgesics B. Keep blood pressure elevated to promote perfusion C. Administer antibiotics as prescribed D. Keep blood pressure within ordered parameters

Correct Answer is D

Explanation

A. Analgesics are important to manage pain and reduce stress, which can help prevent aneurysm rupture.
B. Keeping blood pressure elevated increases the risk of aneurysm rupture and is not appropriate.
C. Antibiotics are not routinely indicated unless there is an infection.
D. Controlling blood pressure reduces stress on the aneurysm wall, minimizing the risk of rupture.

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A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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