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

Explanation

A. Joint inflammation(arthritis) is a common manifestation of systemic lupus erythematosus. SLE can cause inflammation in the joints, leading to symptoms such as pain, swelling, stiffness, and decreased range of motion. It often affects the small joints of the hands, wrists, and knees.

B. Tophi are deposits of uric acid crystals that form under the skin in people with chronic gout.
C. Esophagitis, or inflammation of the esophagus, can occur in systemic lupus erythematosus as part of gastrointestinal involvement. However, it is not one of the most common manifestations of SLE.
D. "Bull's eye" lesion, also known as erythema multiforme, is a skin manifestation seen in conditions such as Lyme disease and certain drug reactions. It is not typically associated with systemic lupus erythematosus.

A. Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr B. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L C. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L D. Regular insulin 20 units subcutaneously E. Blood glucose checks every 4 hr F. Initiate cardiac monitoring G. Insert indwelling urinary catheter H. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

Correct Answer is ["B","C","F","H"]

Explanation

The client has diabetes ketoacidosis (DKA) as seen in the lab findings. The management of DKA involves fluid rehydration with isotonic crystalloids such as normal saline, glycemic control with intravenous insulin infusion and electrolyte supplementation specifically potassium if it is normal or low.

This is because administration of insulin drives potassium ions into the cells leading to hypokalemia Cardiac monitoring is vital to ensure that any dysrhythmias due to electrolyte disturbances are recognized early.

Blood sugar monitoring should be done more frequently- preferably every 1 hour. Although monitoring of output is key, catheterization is unnecessary when the client is awake.

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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

A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find?

Correct Answer is A

Explanation

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Correct Answer is ["B","C","F","H"]

Explanation

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