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A nurse is caring for a client who has a tracheostomy.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The client has manifestations of

and
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Rationale:

Hypoxia: The client's decreased oxygen saturation (SaO2) despite oxygen therapy and the presence of respiratory distress (tachypnea, shortness of breath) indicate hypoxia.

Pneumonia: The client's fever, increased respiratory rate, decreased oxygen saturation, and crackles in the lungs are indicative of pneumonia, particularly in the right lower lobe as evidenced by the chest X-ray.


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Related Questions

Correct Answer is B

Explanation

A. An intolerance to the feedings might cause discomfort, but it would not typically cause increasing pain, fever, and dyspnea. These symptoms are more indicative of a serious complication.
B. Esophageal perforation with fistula formation into the lung is the most likely cause of these symptoms. A perforation can lead to leakage of gastric contents into the pleural space or mediastinum, causing fever, pain, and respiratory distress. The formation of a fistula between the esophagus and the lung would lead to dyspnea.
C. Extension of the tumor into the aorta is a rare complication that would typically manifest with symptoms related to cardiovascular issues, not gastrointestinal symptoms like fever and dyspnea.
D. Leakage of fluids into the mediastinum is a possible cause of the symptoms, but esophageal perforation with a fistula into the lung is more directly linked to these specific symptoms, especially dyspnea.

Correct Answer is A

Explanation

A. A decrease in the white blood cell count toward normal levels indicates that the infection is responding to antibiotic treatment. A WBC count of 6000/μL is within the normal range for adults (usually 4,000–11,000/μL), which suggests that the body is no longer fighting a significant infection.
B. Bronchial breath sounds heard at the right base indicate consolidation, a sign of ongoing pneumonia or unresolved infection. This would suggest that the infection is not yet controlled, rather than an improvement.
C. Increased tactile fremitus indicates consolidation, which is commonly seen in pneumonia. It suggests that the infection is still present and has not resolved with treatment.
D. Green mucus can indicate the presence of purulent sputum and ongoing infection. Although the color of the mucus may change during the course of pneumonia, the presence of green mucus does not confirm that the infection is resolving, especially after three days of antibiotics.

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