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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vomiting may indicate distress but does not pose an immediate threat to life and is not the most urgent concern in an anaphylactic reaction.
B. Stridor is a high-pitched, wheezing sound caused by disrupted airflow, indicating upper airway obstruction. This is a medical emergency and requires immediate intervention to maintain airway patency, making it the top priority.
C. Urticaria (hives) is a common skin manifestation of an allergic reaction but is not life-threatening on its own.
D. Hypotension is a serious sign of anaphylaxis, but airway compromise (stridor) takes precedence according to the ABCs of emergency care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}
Explanation
Anticipated:
Obtain ABGs: This is anticipated because arterial blood gases help evaluate oxygenation and acid-base status. Since the client has a low O₂ saturation (85%) and is showing signs of respiratory distress, ABGs are essential for guiding oxygen therapy and further interventions.
Prepare for insertion of a chest tube: A chest tube is the primary treatment for a pneumothorax. It allows air to escape the pleural space and re-expand the lung. The client's absent breath sounds and labored breathing indicate a significant air accumulation that needs urgent management.
Obtain intravenous access: IV access is essential to administer fluids, analgesics, or emergency medications, especially in a hypotensive client (BP 92/64 mm Hg) showing signs of shock and respiratory compromise.
Computed tomography (CT) of the chest: A CT scan may be ordered to assess the extent of lung injury or to evaluate for concurrent thoracic trauma. It provides more detailed imaging than a chest x-ray and is appropriate once the client is stabilized.
Non-essential:
Thoracentesis: Thoracentesis is used to remove fluid from the pleural space, such as in pleural effusion, not air, as in pneumothorax. Performing thoracentesis in this case could worsen the condition or lead to further complications.
Contraindicated:
Pulmonary Function Tests (PFTs): PFTs are not appropriate in this scenario. They require the client to perform forced breathing maneuvers, which are unsafe and impractical for someone in acute respiratory distress with a pneumothorax.
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