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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A rationale:
Notifying the facility's security department may be necessary in some cases, but it should not be the nurse's first action. This could escalate the situation and make the patient feel threatened or coerced. It's important to first attempt to de-escalate the situation and understand the patient's reasons for wanting to leave. Involving security prematurely could damage the nurse- patient relationship and make it more difficult to provide care in the future.
Security should be involved if the patient is a danger to themselves or others, or if they are attempting to leave in a way that could cause harm. However, in most cases, it is best to try to resolve the situation through communication and understanding.
Choice B rationale:
Calling the patient's family may be helpful in some cases, but it is not always necessary or appropriate. The nurse should first assess the patient's decision-making capacity and their understanding of the risks of leaving against medical advice. If the patient is capable of making their own decisions, the nurse should respect their autonomy and not involve family members without their consent.
Involving family members without the patient's consent could breach confidentiality and erode trust. It's important to balance the patient's right to privacy with the potential benefits of involving family members.
Choice C rationale:
Insisting that the patient exit the hospital via a wheelchair is not necessary in most cases. If the patient is able to walk and does not pose a safety risk, they should be allowed to leave on their own terms. Requiring a wheelchair could be seen as patronizing or controlling, and it could further upset the patient.
The use of a wheelchair should be based on the patient's individual needs and preferences, not on a blanket policy.
Choice D rationale:
Making sure the patient understands that they are leaving against medical advice is the most important action the nurse can take. This ensures that the patient is aware of the potential risks of leaving the hospital, and it protects the nurse from liability. The nurse should document the patient's decision in the medical record and have the patient sign an Against Medical Advice (AMA) form.
By ensuring informed consent, the nurse respects the patient's autonomy while also fulfilling their professional obligations.
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