A nurse is collecting data from a client following removal of the client’s endotracheal tube. What findings should the nurse report to the provider?
Crackles
Stridor
Strong cough
Deep breathing
The Correct Answer is B
Choice B rationale:
Stridor is a high-pitched, whistling sound that is heard during inspiration. It is a sign of upper airway obstruction, indicating a potentially life-threatening complication that requires immediate intervention.
Here's a detailed explanation of why stridor is the most concerning finding and why the other choices are not as indicative of a serious problem:
Stridor:
Mechanism: Stridor occurs when there is narrowing or obstruction of the upper airway, typically at the level of the larynx or trachea. This narrowing can be caused by various factors, including:
Laryngospasm: A sudden constriction of the vocal cords, often triggered by irritation or inflammation. Post-extubation edema: Swelling of the tissues in the airway after removal of the endotracheal tube.
Mucus plugging: Accumulation of thick secretions in the airway, which can partially block airflow.
Vocal cord dysfunction: Impairment of the vocal cords' movement, which can affect their ability to open and close properly.
Significance: Stridor is a serious sign because it indicates that airflow is significantly restricted. If left untreated, upper airway obstruction can lead to hypoxia (low oxygen levels) and respiratory failure.
Nursing intervention: If stridor is present, the nurse should immediately notify the provider and prepare for potential interventions to secure the airway, such as:
Reintubation: Reinserting the endotracheal tube to bypass the obstruction.
Nebulized racemic epinephrine: Medication to reduce swelling in the airway.
Heliox: A mixture of helium and oxygen that can improve airflow through a narrowed airway. Steroids: Medications to reduce inflammation in the airway.
Crackles (Choice A):
Description: Crackles are rattling, crackling sounds heard in the lungs, often during inspiration. They are typically associated with lower airway problems, such as pneumonia or pulmonary edema.
Significance: While crackles can indicate respiratory issues, they are not as immediately concerning as stridor in the context of post-extubation care.
Strong cough (Choice C):
Significance: A strong cough is generally a positive sign after extubation, as it indicates that the patient is able to clear secretions from their airway effectively.
Deep breathing (Choice D):
Significance: Deep breathing is also a positive sign, as it promotes lung expansion and oxygenation.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Elevating the head of the bed can promote comfort and ease breathing, but it's not the first priority in this situation. The nurse needs to assess the client's gastrointestinal status before offering any fluids or food.
While elevating the head of the bed may be helpful in some postoperative situations, it doesn't directly address the client's request for something to drink or the need to assess for potential contraindications to oral intake.
It's important to prioritize assessment before intervention to ensure safe and effective care.
Choice B rationale:
Offering apple juice, a clear liquid, might seem appropriate given the postoperative orders, but it's premature without first assessing the client's abdomen.
Auscultation can reveal important information about bowel sounds, which can indicate whether the client's gastrointestinal system is ready to tolerate fluids or food.
Prematurely offering fluids could lead to complications like nausea, vomiting, or aspiration if the client's bowels are not functioning properly.
Choice D rationale:
Ordering a lunch tray is not appropriate at this stage. The nurse needs to first assess the client's tolerance for clear liquids before advancing the diet.
Advancing the diet too quickly could also lead to gastrointestinal complications.
It's important to follow the postoperative orders and progress the diet gradually as tolerated.
Choice C rationale:
Auscultating the client's abdomen is the essential first step in this scenario. It allows the nurse to gather crucial data about the client's gastrointestinal status.
By listening to bowel sounds, the nurse can determine if the client's intestines are active and functioning properly. If bowel sounds are present and normal, it suggests that the client is likely able to tolerate clear liquids.
If bowel sounds are absent or abnormal, it may indicate a potential problem, such as ileus (a temporary paralysis of the intestines), and the nurse would need to hold oral intake and notify the healthcare provider.
This assessment provides essential information to guide the nurse's subsequent actions and ensure the client's safety.
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.
Choice B rationale:
Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.
Choice C rationale:
Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.
Choice D rationale:
Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.
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