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. Respite care services provide temporary relief and support for caregivers by offering short-term care for their loved ones. This allows caregivers to take a break, attend to their own needs, and prevent burnout. Recommending respite care services is a proactive approach to addressing the caregiver's exhaustion and ensuring the well-being of both the caregiver and the client with Alzheimer's disease.
A. The caregiver's exhaustion and irritability may be due to the stress of caregiving rather than intentional neglect or abuse.
B. Relying on medication to manage stress and sleep may not be the best long-term solution and can potentially lead to dependence or other adverse effects.
C. Contacting hospice services for end-of-life care is not appropriate for a client with moderate Alzheimer's disease unless the client's condition has progressed to a terminal stage. Hospice care focuses on providing comfort and support for individuals with a terminal illness who have a life expectancy of six months or less.

A. Lower the head of the bed to semi-Fowler's. B. Change infusion to lactated Ringer's and maintain rate. C. Slow infusion rate and contact the provider. D. Administer prescribed corticosteroids.

Correct Answer is C

Explanation

A. This position may help alleviate dyspnea by promoting better lung expansion. However, it does not address the underlying issue of fluid overload or the need for urgent action. While helpful for comfort, this action alone is insufficient.
B. Switching the IV fluid to lactated Ringer's solution does not address the issue of fluid overload and is likely to worsen the situation.
C. Slowing the infusion can help mitigate further fluid overload, and contacting the provider is crucial for further evaluation and intervention. This option prioritizes the client’s safety and addresses the symptoms being experienced.
D. Corticosteroids are not typically used to address dyspnea and hypertension associated with IV fluid administration.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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