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 ["A","C","D","E","G"]

Explanation

Improvement in blood pressure would suggest better cardiovascular stability

A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.

An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.

A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.

A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.

Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.

A. Strawberries B. Shellfish C. Avocados D. Eggs

Correct Answer is D

Explanation

D. Propofol is an emulsion formulation that contains egg lecithin as an ingredient. Therefore, individuals with an egg allergy may be at risk for allergic reactions to propofol. It is essential for the nurse to identify any egg allergies in preoperative clients to prevent potential adverse reactions to propofol.
A. Propofol is not derived from strawberries, and there is no cross-reactivity between propofol and strawberries.
B. While shellfish allergies are common, there is no known cross-reactivity between shellfish and propofol.
C. Avocado allergy is not associated with potential reactions to propofol.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D","E","G"]

Explanation

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Correct Answer is D

Explanation

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