A nurse is caring for a client who has a tracheostomy.
Drag words from the choices below to fill in each blank in the following sentence.
The client has manifestations of
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A fever following an upper gastrointestinal endoscopy can be a sign of a serious complication, such as perforation, which could cause peritonitis. The nurse should promptly assess the client for other signs of perforation, such as abdominal pain, rigidity, or changes in vital signs. This is a critical and potentially life-threatening situation that requires immediate attention.
B. While it is important to ensure accurate temperature readings, a fever of 101.8°F in a post-procedural patient is concerning and warrants further investigation rather than just retaking the temperature. It may indicate a complication such as infection or perforation.
C. Administering acetaminophen to reduce the fever is not the first step. The nurse should prioritize investigating the underlying cause of the fever, as it could indicate a more serious complication like perforation, which would not be resolved by medication alone.
D. Bathing the client with tap water is not appropriate. A fever after a procedure should be investigated thoroughly rather than treated symptomatically without understanding the cause. The nurse should focus on assessing for complications first.
Correct Answer is A
Explanation
A. Brushing the client's teeth with a suction toothbrush every 12 hours is a key intervention to reduce the risk of ventilator-associated pneumonia (VAP). Oral hygiene helps to decrease the accumulation of bacteria in the mouth, which could potentially be aspirated into the lungs and cause infection. This should be done more frequently, often every 4–6 hours, to reduce bacterial colonization.
B. Providing humidity to the ventilator tubing is necessary to maintain adequate moisture and prevent airway dryness, but it does not directly reduce the risk of VAP. Oral care and head-of-bed positioning are more crucial in preventing infection.
C. The head of the client's bed should be kept elevated, not flat, to reduce the risk of aspiration, which can lead to VAP. Keeping the head of the bed at a 30–45 degree angle is recommended.
D. Turning the client every 4 hours is important for preventing pressure ulcers and promoting circulation but is not the most effective intervention for reducing the risk of VAP. Frequent oral care and appropriate positioning are more important.
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