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

Explanation

A. Urine output should increase with adequate fluid replacement, not decrease.
B. Weight may increase with fluid resuscitation due to fluid accumulation; a decrease is not a reliable sign of adequate resuscitation in the acute phase.
C. Heart rate. In burn patients, tachycardia is often a compensatory response to hypovolemia. A decrease in heart rate indicates improving circulatory volume and perfusion, suggesting effective fluid resuscitation.
D. Blood pressure should increase or stabilize with adequate fluids; a decrease suggests inadequate perfusion or ongoing hypovolemia.

A. Check the pedal pulses. B. Verify the most recent calcium level. C. Request prescription for a relaxant. D. Administer an oral potassium supplement.

Correct Answer is B

Explanation

A. Checking pedal pulses assesses circulation but will not help identify the cause of muscle spasms in this context.
B. Muscle spasms following a thyroidectomy may indicate hypocalcemia, a common complication due to accidental removal or damage to the parathyroid glands during surgery. This electrolyte imbalance can lead to neuromuscular excitability and tetany, which requires prompt recognition and treatment.
C. Requesting a relaxant may mask symptoms without addressing the underlying cause, delaying appropriate treatment.
D. Administering potassium is not appropriate unless hypokalemia is confirmed; muscle spasms in this scenario are more likely due to low calcium, not potassium.

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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

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Correct Answer is C

Explanation

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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