A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)
Inspiratory stridor
Nausea
Retractions
Muscle tremors
Cyanosis
Correct Answer : A,C,E
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration that indicates partial obstruction of the upper airway. It is a characteristic sign of airway obstruction and requires immediate attention.
B. Nausea
Nausea is not a common manifestation of airway obstruction. It may be associated with other conditions such as gastrointestinal issues or medication side effects but is not directly related to airway obstruction.
C. Retractions
Retractions refer to visible sinking of the skin between the ribs and above the clavicles during inspiration, which indicates increased effort to breathe. Retractions can occur in response to airway obstruction, as the body attempts to overcome the resistance to breathing.
D. Muscle tremors
Muscle tremors are not specific manifestations of airway obstruction. Tremors may occur due to various reasons such as anxiety, electrolyte imbalances, or neurological conditions but are not typically associated with airway obstruction.
E. Cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It can occur with airway obstruction as oxygen exchange is compromised. Cyanosis is a late sign of respiratory distress and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
First, we need to find out how many milligrams (mg) are in 1 milliliter (mL) of the available diphenhydramine solution:
12.5 mg/5 mL
To find out how many milligrams are in 1 mL, we divide the total milligrams by the total milliliters:
12.5 mg ÷ 5 mL = 2.5 mg/mL
Now that we know the concentration of diphenhydramine is 2.5 mg/mL, we can calculate the dose needed for the order of 25 mg:
25 mg ÷ 2.5 mg/mL = 10 mL
Correct Answer is C
Explanation
A. "I'll rinse my mouth after taking this medication."
Montelukast is taken orally and is not associated with the risk of oral thrush or other mouth-related side effects that would require rinsing the mouth after administration. This action is more commonly associated with inhaled corticosteroids, not leukotriene receptor antagonists.
B. "I'll use this medication when I get an asthma attack."
Montelukast is not a rescue medication for asthma attacks. It is a long-term controller medication used to manage and prevent asthma symptoms, not to treat acute attacks. Short-acting bronchodilators such as albuterol are used for quick relief during asthma attacks.
C. "I'll take this medication once a day in the evening."
Montelukast is a leukotriene receptor antagonist commonly used to manage asthma. It is typically taken orally once daily, usually in the evening, to provide 24-hour control of asthma symptoms and improve lung function. Therefore, the statement indicating an understanding of the teaching is option C.
D. "I'll decrease my sodium intake while I'm taking this medication."
Montelukast is not known to affect sodium levels in the body or require any specific dietary modifications, such as decreasing sodium intake. Therefore, this statement is unrelated to the use of montelukast for asthma management
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