Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is C

Explanation

A. Furosemide is a diuretic that is used to reduce fluid overload and manage conditions like heart failure or kidney disease. It is not indicated in anaphylaxis.
B. Methylprednisolone is a corticosteroid used for its anti-inflammatory properties and can be used in anaphylaxis to reduce inflammation and prevent delayed reactions. However, it is not the first-line treatment in acute anaphylactic shock.
C. Epinephrine is the first-line treatment for anaphylactic shock. It works by rapidly reversing the effects of anaphylaxis, such as bronchoconstriction, vasodilation, and edema, by stimulating alpha and beta receptors. Epinephrine should be administered as soon as anaphylaxis is suspected to stabilize the patient’s condition.
D. Dobutamine is a medication used to manage shock by increasing cardiac output, but it is not used in the management of anaphylactic shock. The priority is epinephrine to reverse the anaphylactic response.

A. Have the client refrain from talking for 24 hr. B. Withhold food and liquids until the client's gag reflex returns. C. Irrigate the client's throat every 4 hr. D. Suction the client's oropharynx frequently.

Correct Answer is B

Explanation

A. Have the client refrain from talking for 24 hr.: This is unnecessary; the client may talk once the effects of the local anesthetic wear off, typically within an hour or two after the procedure.
B. Withhold food and liquids until the client's gag reflex returns: This is the most important action to prevent aspiration. After a bronchoscopy, the throat is anesthetized, and eating or drinking before the gag reflex returns increases the risk of aspiration.
C. Irrigate the client's throat every 4 hr.: This is not a routine post-procedure intervention and could be uncomfortable for the client.
D. Suction the client's oropharynx frequently: Suctioning should only be performed if the client has difficulty clearing secretions. There is no routine need for frequent suctioning after a bronchoscopy unless clinically indicated.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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Naxlex Comprehensive Predictor Exams

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