A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)
Inspiratory stridor
Nausea
Retractions
Muscle tremors
Cyanosis
Correct Answer : A,C,E
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration that indicates partial obstruction of the upper airway. It is a characteristic sign of airway obstruction and requires immediate attention.
B. Nausea
Nausea is not a common manifestation of airway obstruction. It may be associated with other conditions such as gastrointestinal issues or medication side effects but is not directly related to airway obstruction.
C. Retractions
Retractions refer to visible sinking of the skin between the ribs and above the clavicles during inspiration, which indicates increased effort to breathe. Retractions can occur in response to airway obstruction, as the body attempts to overcome the resistance to breathing.
D. Muscle tremors
Muscle tremors are not specific manifestations of airway obstruction. Tremors may occur due to various reasons such as anxiety, electrolyte imbalances, or neurological conditions but are not typically associated with airway obstruction.
E. Cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It can occur with airway obstruction as oxygen exchange is compromised. Cyanosis is a late sign of respiratory distress and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Start slowly and increase volume over several sessions.
This is the correct choice. For clients having difficulty using an incentive spirometer, starting slowly and gradually increasing the volume over several sessions is an appropriate approach. It allows the client to become familiar with the device and the technique required for effective use. Starting slowly also reduces the risk of discomfort or respiratory distress, allowing the client to build up their lung capacity gradually and achieve optimal results over time.
B. Do regular deep-breathing exercises instead.
Regular deep-breathing exercises are beneficial for improving lung function and respiratory strength. However, using an incentive spirometer serves a specific purpose in promoting deep breathing and lung expansion to prevent atelectasis (lung collapse) and improve respiratory function. While deep-breathing exercises are helpful, they may not provide the same targeted benefits as using an incentive spirometer, especially for clients who are experiencing difficulty with deep breathing or lung expansion.
C. Use another device because this one might be faulty.
This option assumes that the difficulty with the incentive spirometer is due to a fault in the device itself, which may not necessarily be the case. Before considering another device, it's important to ensure that the client is using the current device correctly and receiving proper instruction. If the client continues to have difficulty despite proper technique and instruction, then further assessment of the device may be warranted.
D. Be much more vigorous in increasing increments.
Being much more vigorous in increasing increments is not recommended, as it could lead to discomfort, respiratory distress, or hyperventilation for the client. Increasing the volume too quickly may overwhelm the client and make it more difficult for them to use the incentive spirometer effectively. Gradual progression allows the client to adjust to the device and build up their lung capacity safely and effectively over time.
Correct Answer is C
Explanation
A. Saving the sputum specimen in a clean container.
While it is important to collect the sputum specimen in a clean, sterile container, simply saving the specimen in a clean container is not sufficient. The nurse needs to actively collect the sputum specimen from the client using proper technique to ensure that it is not contaminated and is suitable for laboratory analysis.
B. Collecting the sputum specimen after a meal.
Collecting a sputum specimen after a meal is not recommended, as it can increase the likelihood of contamination with food particles. It's preferable to collect the specimen before meals or at least 1-2 hours after eating to minimize the risk of contamination and ensure the integrity of the specimen.
C. Rinse the client's mouth before collecting the specimen.
When obtaining a sputum specimen from a client, it's important for the nurse to plan to rinse the client's mouth before collecting the specimen. Rinsing the mouth with water helps to clear any food particles or debris from the oral cavity, ensuring that the sputum sample collected is not contaminated with saliva or food particles. This improves the quality and accuracy of the specimen for laboratory analysis.
D. Obtaining the specimen from the client in the evening.
The timing of specimen collection is not necessarily restricted to the evening. The timing may vary depending on the client's condition and the healthcare provider's orders. It's important to follow the healthcare provider's instructions regarding the timing of specimen collection, which may be based on factors such as the client's symptoms and the diagnostic requirements.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.