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The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
- A. Obtain vital signs.
- B. Monitor heart rhythm.
- C. Auscultate lung sounds.
- D. Assess capillary refill.
Correct Answer: C
Rationale: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.
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The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?
- A. Lung fields
- B. Voiding
- C. Joint pain
- D. Mentation
Correct Answer: B
Rationale: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications,including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
- A. Copious mucous secretions
- B. Sudden restlessness
- C. Harsh cough
- D. Bilateral breath sounds present
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.
- A. A decreased respiratory rate
- B. Arterial blood gases reporting a $\mathrm{PaCO}_2$ of 48 and a $\mathrm{PaO}_2$ of 84
- C. Nasal flaring with abdominal retractions
- D. Administration of a corticosteroid inhaler for quick relief
- E. Lung sounds of wheezing
- F. Increased respiratory effort
Correct Answer: B,C,E,F
Rationale: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated $\mathrm{CO}_2$ and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratorycompromise. Administration of a corticosteroid decreases inflammation over a period of time.
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, 'Elevate the head of the bed 45 degrees.' This assists in meeting which nursing goal?
- A. The client will have decreased pain.
- B. The client will remain alert and oriented.
- C. The client will have decreased edema.
- D. The client will have increased tissue perfusion.
Correct Answer: C
Rationale: Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase theblood supply.
The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be sure to include regarding cold tablets containing first-generation antihistamines?
- A. They dilute the nasal secretions.
- B. They lead to frequent sinus drainage.
- C. They can cause urinary hesitancy.
- D. They prolong bleeding.
Correct Answer: C
Rationale: The nurse should include information about the side effect of urinary hesitancy with first-generation antihistamines. This class of drugs can also cause drowsiness and dry mouth. Aspirin prolongs bleeding.