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 B
Explanation
A. Petroleum jelly should not be used on the nares with oxygen therapy, as it is flammable and could pose a fire hazard. Non-petroleum-based lubricants should be used if needed.
B. A humidifier should be attached to the flow meter when delivering oxygen at higher flow rates (such as 6 L/min) to prevent dryness and irritation of the mucous membranes in the nose and throat.
C. The nasal cannula should generally be kept on during meals to ensure continued oxygen therapy, unless it is uncomfortable or the client has other medical needs.
D. The oxygen tubing should be secured to the client’s body or clothing in a way that does not restrict movement or cause injury, but securing it to the bed sheet could lead to a potential tripping hazard or interfere with mobility.
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.
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