A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

Crackles

Stridor

Strong cough

Deep breathing

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:

Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.

Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.

Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.

Blood or secretions in the airway: These can obstruct the airway and cause stridor.

It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:

Oxygen therapy: This can help to improve the patient's breathing.

Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.

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Correct Answer is D

Explanation

The correct answer is choiceD.

Choice A rationale:

Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.

A. Respiratory acidosis. B. Respiratory alkalosis. C. Metabolic acidosis. D. Metabolic alkalosis.

Correct Answer is D

Explanation

Choice A rationale:

Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.

The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).

Choice B rationale:

Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.

The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.

Choice C rationale:

Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.

The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).

Choice D rationale:

Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.

The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).

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A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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