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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 D

Explanation

A. Cheddar cheese contains lactose and is not an ideal choice for a low-lactose diet, as it may cause discomfort in clients who are lactose intolerant.
B. Cottage cheese also contains lactose, though in smaller amounts than some other dairy products, but it is still not the best choice for someone on a low-lactose diet.
C. Low-fat yogurt may contain some lactose, but it also contains probiotics, which can help with digestion and may be tolerated better than other dairy products. However, for someone on a strict low-lactose diet, it may not be the best choice.
D. Soymilk is a non-dairy alternative and is typically lactose-free, making it the best choice for someone on a low-lactose diet. It provides a dairy-free option for those needing to avoid lactose.

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.

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