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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Refer questions to the nursing supervisor.
Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.
Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.
Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.
Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.
Correct Answer is C
Explanation
Choice A rationale:
Intractable pain is pain that is persistent and does not respond to usual pain management methods. While angina can be intractable in some cases, it does not typically manifest as pain in the arm and jaw. Moreover, the patient in this scenario has not yet undergone pain management efforts, so it's premature to classify the pain as intractable.
Choice B rationale:
Phantom pain is pain that is felt in a part of the body that has been amputated or is no longer there. The patient in this scenario has not experienced any amputations, so phantom pain is not a valid explanation for the arm and jaw pain.
Choice C rationale:
Referred pain is pain that is felt in a part of the body that is different from the source of the pain. This is the most likely explanation for the arm and jaw pain in this patient. The heart and the arm and jaw share nerve pathways, so pain signals from the heart can be misinterpreted by the brain as coming from these other areas. This is a common phenomenon in patients with angina.
Choice D rationale:
Cramping pain is a type of pain that is often described as a muscle tightening or squeezing sensation. It is not typically associated with angina. While angina can sometimes cause chest tightness, it's not characterized by cramping in the arm and jaw.
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