After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?

Instruct the client to use the incentive spirometer hourly.

Assess client for a raw and sore throat.

Encourage the client to turn, cough, and deep breath.

Listen to the lungs for upper airway stridor.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Instruct the client to use the incentive spirometer hourly: Incentive spirometry promotes alveolar expansion and prevents atelectasis, but it does not address acute post-extubation airway compromise. An anxious, hyperventilating client may be unable to coordinate effective spirometry. Airway patency must be evaluated first.

B. Assess client for a raw and sore throat: Throat irritation is common after prolonged intubation and may contribute to discomfort or anxiety. However, it does not explain acute respiratory distress or rapid breathing. This assessment is secondary to evaluating airway obstruction.

C. Encourage the client to turn, cough, and deep breath: These measures improve secretion clearance and ventilation but may worsen distress if airway edema or obstruction is present. Encouraging deep breathing without first assessing the airway may delay recognition of a critical complication.

D. Listen to the lungs for upper airway stridor: Stridor indicates upper airway obstruction, often due to laryngeal edema after prolonged intubation. Early identification is critical because it can rapidly progress to respiratory failure. Airway assessment is the immediate priority following extubation with new-onset anxiety and hyperventilation.

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Correct Answer is B

Explanation

Rationale:
A. Medicate for pain prior to moving the client: Pain control improves comfort and cooperation during transport, but it does not directly prevent a life-threatening complication related to chest tube function during movement.

B. Keep the drainage system below the insertion site: Maintaining the drainage system below chest level prevents backflow of air or fluid into the pleural space, which could cause a pneumothorax or compromise lung re-expansion during transport.

C. Send the client to radiology via stretcher: A stretcher is appropriate for safety, but it does not address the priority risk associated with chest tube mechanics and pleural pressure changes.

D. Mark the drainage amount on the collection chamber: Tracking output is important for ongoing assessment, but it is not the most immediate intervention required to ensure chest tube safety during transport.

A. Spray a mist of water on the face and direct airflow on client. B. Assess for confusion or change in level of consciousness. C. Encourage client to drink cool beverages without caffeine. D. Obtain blood samples for serum electrolytes evaluation.

Correct Answer is A

Explanation

Rationale:
A. Spray a mist of water on the face and direct airflow on client: Rapid cooling is the priority in suspected heat stroke with a core temperature above 104°F. Evaporative cooling is an immediate, effective intervention to reduce body temperature and prevent organ damage.

B. Assess for confusion or change in level of consciousness: The client is already unconscious, indicating severe neurologic impairment. Further assessment can occur after initiating life-saving cooling measures.

C. Encourage client to drink cool beverages without caffeine: Oral fluids are contraindicated because the client is unconscious and at high risk for aspiration. Cooling must be achieved through external methods.

D. Obtain blood samples for serum electrolytes evaluation: Laboratory evaluation is important but should not delay immediate interventions aimed at rapidly lowering the client’s dangerously elevated body temperature.

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After seven days of mechanical ventilation, an older adult client is extubated and is now receiving 50% oxygen via face mask. The client has become anxious and is beginning to hyperventilate. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is A

Explanation

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