A nurse is collecting data from a client following removal of the client’s endotracheal tube. What findings should the nurse report to the provider?

Crackles

Stridor

Strong cough

Deep breathing

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Stridor is a high-pitched, whistling sound that is heard during inspiration. It is a sign of upper airway obstruction, indicating a potentially life-threatening complication that requires immediate intervention.

Here's a detailed explanation of why stridor is the most concerning finding and why the other choices are not as indicative of a serious problem:

Stridor:

Mechanism: Stridor occurs when there is narrowing or obstruction of the upper airway, typically at the level of the larynx or trachea. This narrowing can be caused by various factors, including:

Laryngospasm: A sudden constriction of the vocal cords, often triggered by irritation or inflammation. Post-extubation edema: Swelling of the tissues in the airway after removal of the endotracheal tube.

Mucus plugging: Accumulation of thick secretions in the airway, which can partially block airflow.

Vocal cord dysfunction: Impairment of the vocal cords' movement, which can affect their ability to open and close properly.

Significance: Stridor is a serious sign because it indicates that airflow is significantly restricted. If left untreated, upper airway obstruction can lead to hypoxia (low oxygen levels) and respiratory failure.

Nursing intervention: If stridor is present, the nurse should immediately notify the provider and prepare for potential interventions to secure the airway, such as:

Reintubation: Reinserting the endotracheal tube to bypass the obstruction.

Nebulized racemic epinephrine: Medication to reduce swelling in the airway.

Heliox: A mixture of helium and oxygen that can improve airflow through a narrowed airway. Steroids: Medications to reduce inflammation in the airway.

Crackles (Choice A):

Description: Crackles are rattling, crackling sounds heard in the lungs, often during inspiration. They are typically associated with lower airway problems, such as pneumonia or pulmonary edema.

Significance: While crackles can indicate respiratory issues, they are not as immediately concerning as stridor in the context of post-extubation care.

Strong cough (Choice C):

Significance: A strong cough is generally a positive sign after extubation, as it indicates that the patient is able to clear secretions from their airway effectively.

Deep breathing (Choice D):

Significance: Deep breathing is also a positive sign, as it promotes lung expansion and oxygenation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Tenderness to touch is a common finding in wounds healing by secondary intention. It's often due to inflammation, which is a normal part of the healing process. The inflammation brings in cells and substances that promote healing. However, increased tenderness, especially when accompanied by other signs of infection, should be reported.

Choice B rationale:

A halo of erythema on the surrounding skin is a sign of infection. This is a serious complication that can delay healing and lead to further complications. The erythema indicates that the infection is spreading beyond the wound edges and needs prompt attention.

Choice C rationale:

Drainage of serosanguineous fluid is also common in wounds healing by secondary intention. This fluid is a mixture of serum (clear yellowish fluid) and blood. It's a sign that the wound is cleaning itself and new tissue is forming. While excessive drainage or a change in color or odor could signal a problem, drainage itself is not necessarily a cause for concern.

Choice D rationale:

Pink, shiny tissue with a granular appearance is a sign of healthy granulation tissue. This is a type of tissue that forms during the healing process. It's rich in blood vessels and collagen, which are essential for wound healing. The presence of granulation tissue indicates that the wound is healing well.

A. A patient who has heart failure and is receiving diuretic therapy. B. A patient who has gastroenteritis and is receiving oral fluids. C. A patient who has end-stage kidney disease who will undergo dialysis. D. A patient who has NPO status since midnight for an endoscopy.

Correct Answer is D

Explanation

Rationale for Choice A:

Diuretics promote fluid loss, increasing the risk of fluid volume deficit.

Heart failure can lead to fluid retention, but diuretic therapy is often used to manage this excess fluid.

However, in this case, the patient is receiving diuretic therapy, which suggests that their fluid status is being actively managed.

Therefore, while this patient is at risk for fluid volume deficit, they are not the most likely candidate among the options presented.

Rationale for Choice B:

Gastroenteritis can lead to fluid loss through vomiting and diarrhea.

However, this patient is receiving oral fluids, which helps to replenish lost fluids and electrolytes.

As long as the patient is able to tolerate oral fluids and is not experiencing excessive fluid losses, they are not at significant risk for fluid volume deficit.

Rationale for Choice C:

End-stage kidney disease can impair the kidneys' ability to regulate fluid balance.

However, dialysis is a treatment that helps to remove excess fluid and waste products from the body.

Therefore, while this patient is at risk for fluid volume imbalances, they are receiving treatment to manage this risk.

Rationale for Choice D:

NPO status means that the patient has been instructed to have nothing by mouth. This means that the patient has not been able to consume any fluids since midnight.

Even in the absence of excessive fluid losses, this prolonged period of fluid restriction can lead to dehydration and fluid volume deficit.

Therefore, this patient is the most likely to be experiencing fluid volume deficit among the options presented.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from a client following removal of the client’s endotracheal tube. What findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

Correct Answer is B

Explanation

A nurse is collecting data about the fluid status of four patients.Which patient should the nurse identify as being at risk for fluid volume deficit?

Correct Answer is D

Explanation

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). Which of the following should the nurse include as a common cause of these infections?

A nurse is providing postoperative care for a patient who has a closed-wound drainage system. Which of the following actions should the nurse perform?

A nurse is developing a care plan for a patient with pneumonia who requires chest percussion, vibration, and postural drainage. What should the nurse plan to do first?

A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

A nurse is caring for a patient on the third day following abdominal surgery. The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?

A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.What type of drainage should the nurse report?

What are the appropriate interventions for a patient experiencing anaphylactic shock from a bee sting? (Select all that apply)

A nurse is caring for a client who has heart failure and respiratory arrest. What should be the nurse’s first action?