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
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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Related Questions
Correct Answer is B
Explanation
B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.
Correct Answer is D
Explanation
D. After treatment for primary syphilis, it is essential for the client to have follow-up blood tests to monitor their response to treatment and ensure that the infection has been adequately treated. The follow-up blood tests are typically performed at 3, 6, and 12 months after treatment to check for resolution of the infection.
A. Syphilis is caused by a bacterial infection, not a virus. Therefore, antiviral medications are not effective for treating syphilis.
B. Cryotherapy, which involves freezing off warts or abnormal tissue, is not a treatment for syphilis.
C. Monitoring for 15 minutes after receiving each medication dose is a standard precaution for certain medications, such as vaccines or allergy injections, to monitor for any immediate adverse reactions. However, it is not necessary for syphilis.
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