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 C
Explanation
A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.
Correct Answer is C
Explanation
A. A rosebud-like stoma orifice is a normal finding. It refers to a stoma that has a rounded, pink appearance, which is healthy and typical after surgery.
B. A shiny, moist stoma is a normal finding. This appearance indicates good circulation and healing.
C. A purplish-colored stoma is abnormal and should be reported to the provider immediately. This color suggests possible ischemia or poor circulation, which may require intervention to prevent complications such as necrosis of the stoma.
D. Stoma oozing red drainage is normal, especially in the early postoperative period. It indicates that the stoma is healing properly. However, if the drainage is excessive or if the client shows signs of infection, it would need further evaluation.
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