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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Related Questions
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.
Correct Answer is C
Explanation
A. Administering a broad-spectrum antibiotic is not the first action in this case. The first priority is to assess the situation and obtain a culture of the drainage to identify any infection before initiating antibiotics.
B. While notifying the healthcare provider is important, it is more important to take an initial action by obtaining a culture specimen. Waiting without taking action could delay appropriate care.
C. The best first action is to obtain a culture of the drainage to identify any potential infection, apply a sterile dressing, and continue to monitor the site for further signs of infection. Culturing the drainage helps guide the appropriate treatment.
D. Removing the sutures is not the appropriate action. The sutures should not be removed unless there is clear indication, as this could disrupt the integrity of the catheter placement.
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