A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

Sore throat

SaO, 92%

Stridor

Rhonchi

Answer and Explanation

The Correct Answer is C

C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.

A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.

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Correct Answer is D

Explanation

D. Diet plays a crucial role in managing ulcerative colitis symptoms. Certain foods may trigger flare-ups, while others may be better tolerated. A dietitian can provide personalized dietary advice to help manage symptoms, ensure adequate nutrition, and optimize overall health.
A. Ulcerative colitis is a chronic inflammatory bowel disease that primarily affects the colon and rectum. While pain management is crucial, it is not a priority at this point.
B. Hospice services are generally provided to individuals who have a terminal illness and are nearing the end of life. While ulcerative colitis can be a serious condition, it is not typically considered a terminal illness in itself.
C. A wound, ostomy, and continence nurse (WOCN) specializes in the care of patients with ostomies (such as those resulting from surgery for ulcerative colitis), wounds, and continence issues. The client does not require the services at this point as the decision for the surgery has not been made.

A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

Correct Answer is C

Explanation

A. Monitoring of vital signs should be more frequent

B. This is an important infection control measure for immunocompromised clients. However, this is more about environmental control and may not directly address the specific isolation protocols regarding direct person-to-person transmission.
C. Wearing an N95 respirator may be recommended for direct care, especially if there is concern about exposure to airborne infections from the environment, staff, or visitors.
D. While disposable plates and utensils are generally preferred for infection control, this is not a specific intervention for protective isolation.

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A nurse is assessing a client following extubation from a Ventilator. For which of the following findings should the nurse intervene immediately?

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