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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have the client refrain from talking for 24 hr: The client only needs to refrain from talking until the anesthesia wears off, usually within an hour. There is no need to refrain from talking for 24 hours.
B. Withhold food and liquids until the client's gag reflex returns: This is the correct action. Following a bronchoscopy, the local anesthetic used can suppress the gag reflex. It is crucial to wait until the gag reflex returns to prevent aspiration when the client eats or drinks. C. Irrigate the client's throat every 4 hr: There is no indication to irrigate the throat routinely. The priority is to ensure that the gag reflex has returned before allowing oral intake.
D. Suction the client's oropharynx frequently: Suctioning is only necessary if the client is unable to clear their secretions or has difficulty breathing. It is not a standard post-procedure intervention.
Correct Answer is B
Explanation
A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.