A nurse is caring for a client immediately following endotracheal intubation. The nurse should assess the client for complications by performing which of the following priority action?

Auscultate lungs for the presence of breath sounds

Assess baseline level of consciousness

Assess for the presence of circumoral cyanosis

Determine that the pulse oximetry is greater than 95%.

Answer and Explanation

The Correct Answer is A

A. Auscultate lungs for the presence of breath sounds: This is the priority action following endotracheal intubation, as it directly assesses the effectiveness of the intubation. Auscultating the lungs allows the nurse to confirm that the endotracheal tube is properly positioned in the trachea and that air is reaching the lungs. Abnormal breath sounds, such as decreased or absent sounds on one side, may indicate improper placement or complications like a pneumothorax, making this assessment critical for patient safety.
B. Assess baseline level of consciousness: While assessing the client's level of consciousness is important for evaluating their overall neurological status, it is not the immediate priority following intubation. Changes in consciousness can be influenced by various factors, including sedation or hypoxia, but ensuring proper airway placement and ventilation is more urgent to prevent respiratory compromise.
C. Assess for the presence of circumoral cyanosis: Circumoral cyanosis can indicate inadequate oxygenation, but it may not be immediately apparent after intubation. This assessment is important, but it is secondary to confirming that breath sounds are present and that the airway is secure. Identifying airway placement issues is more crucial before evaluating for signs of hypoxia.
D. Determine that the pulse oximetry is greater than 95%: Monitoring pulse oximetry is essential for assessing oxygen saturation and identifying potential hypoxia. However, if the endotracheal tube is not properly placed, the pulse oximetry may not accurately reflect the client’s respiratory status. Therefore, ensuring proper ventilation through auscultation of breath sounds takes precedence over solely relying on pulse oximetry readings.

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Correct Answer is C

Explanation

A. Client develops ecchymosis at the venipuncture site. Minor bruising at venipuncture sites is a common and expected side effect of heparin therapy due to its anticoagulant effect. While the nurse should monitor for increased bruising, isolated ecchymosis at an IV site does not necessarily indicate excessive anticoagulation or require immediate provider notification.
B. PTT 70 seconds (control 25-40). Heparin therapy is adjusted based on the activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5 to 2.5 times the control value, which in this case would be approximately 60-100 seconds. A PTT of 70 seconds is within the therapeutic range, so it does not require urgent intervention.
C. Client develops hematuria. Hematuria is a sign of potential excessive anticoagulation or internal bleeding, which can be a serious complication of heparin therapy. This finding suggests that the client's coagulation status may need immediate reassessment, and the heparin infusion may require adjustment or reversal with protamine sulfate if necessary. The healthcare provider should be notified promptly.
D. Order for Coumadin 2.5 mg to begin today. It is common practice to start warfarin (Coumadin) while a client is on heparin therapy because warfarin takes several days to reach therapeutic levels. Heparin is typically continued until the INR reaches a therapeutic range. Therefore, this order does not require provider notification.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Pneumonia: The client's chest x-ray shows right lower lobe opacity, which is indicative of pneumonia. The presence of thick yellow secretions, coarse crackles, and diminished breath sounds in the right lower lobe further supports this diagnosis. Additionally, the client's increased temperature (39.4°C) and respiratory rate (24/min) are consistent with an infectious process such as pneumonia.

Hypoxia: The client exhibits hypoxia, as evidenced by the oxygen saturation (SaO2) levels of 88% and 92% while receiving 40% humidified oxygen. The dusky appearance of the buccal mucosa is a visible sign of inadequate oxygenation. Hypoxia is a critical condition that can arise from pneumonia due to impaired gas exchange in the lungs.

Angina: Angina refers to chest pain or discomfort due to inadequate blood supply to the heart muscle, typically caused by coronary artery disease. In this case, there is no mention of chest pain or other cardiac symptoms in the client’s notes. Therefore, while angina could be a concern in patients with respiratory distress due to potential cardiac strain, it is not relevant in this scenario based on the provided information.

Stage II Hypertension: Stage II hypertension is characterized by blood pressure readings of 140/90 mm Hg or higher. The client’s blood pressure reading of 128/76 mm Hg does not indicate hypertension; it falls within the normal range. Therefore, this condition is not applicable in this case. While it is important to monitor blood pressure in all patients, it is not relevant to the client’s current respiratory issues.

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A nurse is caring for a client who has a tracheostomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client has manifestations of dropdownanddropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

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