A nurse is caring for a client who has a tracheostomy.
Drag words from the choices below to fill in each blank in the following sentence.
The client has manifestations of
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Rationale:
Hypoxia: The client's decreased oxygen saturation (SaO2) despite oxygen therapy and the presence of respiratory distress (tachypnea, shortness of breath) indicate hypoxia.
Pneumonia: The client's fever, increased respiratory rate, decreased oxygen saturation, and crackles in the lungs are indicative of pneumonia, particularly in the right lower lobe as evidenced by the chest X-ray.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While obesity can contribute to various health issues, it is not a direct cause of esophageal varices.
B. Smoking is harmful to overall health, but it is not specifically known to cause esophageal varices.
C. High blood pressure, especially systemic hypertension, is not a direct cause of esophageal varices. However, portal hypertension, which can be caused by liver disease, is the main factor in the development of esophageal varices.
D. Chronic liver disease, particularly cirrhosis, leads to portal hypertension, which in turn causes the veins in the esophagus to become engorged and prone to bleeding, resulting in esophageal varices. This is the most appropriate cause for esophageal varices.
Correct Answer is D
Explanation
A. This is an appropriate statement. Most patients with an ileostomy can resume physical activities and exercise, though they should be mindful of their stoma and pouch during activities.
B. This is a correct statement. The pouch should be emptied when it is about one-third to one-half full to prevent it from becoming too heavy or causing skin irritation.
C. This is also correct. Adhesive remover can be used to gently remove the pouch and adhesive, preventing irritation to the skin around the stoma.
D. This statement indicates a need for more teaching. While many foods can be eaten after an ileostomy, some foods may cause blockages or discomfort (e.g., nuts, seeds, and high-fiber vegetables). Patients need to be educated on dietary modifications and precautions post-ileostomy.
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