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. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.

C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.

A. Chloride level B. Creatinine kinase C. Uric acid D. Intrinsic factor

Correct Answer is C

Explanation

C. Uric acid is the end product of purine metabolism, and elevated levels of uric acid in the blood can predispose individuals to gout. In acute gout, there is often a marked increase in serum uric acid levels due to the release of uric acid from the breakdown of purines during the inflammatory process.
A. Chloride level is not directly associated with acute gout.
B. Creatinine kinase (CK) is an enzyme found in various tissues, including muscle tissue. Elevated CK levels are associated with muscle damage or injury, such as in cases of muscle trauma, myocardial infarction, or rhabdomyolysis.
D. Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach that is necessary for the absorption of vitamin B12 in the small intestine.

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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

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