The nurse assists in the extubation of a patient recovering from injuries caused by a motor vehicle crash. Which observations indicate that the patient is able to independently maintain an airway?
Select all that apply.
1. The patient is coughing.
2. The patient has a hoarse voice.
3. The patient has inspiratory stridor.
4. The patient's oxygen saturation 75%.
5. The patient swallows small sips of water.
Correct Answer: 1, 2, 5
When the patient is able to maintain effective respirations and ventilatory support is no longer required, the endotracheal tube is removed (extubation). Cough and swallow reflexes must be intact to prevent aspiration. A hoarse voice is common after extubation. Inspiratory stridor within the first 24 hours indicates laryngeal edema, which may necessitate reintubation. An oxygen saturation of 75% indicates that the patient is not receiving adequate oxygen. Reintubation may be necessary.
You might also like to view...
A 77-year-old female diagnosed with chronic obstructive pulmonary disease (COPD) is experiencing impaired gas exchange and CO2 retention, despite a rapid respiratory rate
Which of the following pathophysiological principles would her health care team expect if her compensatory mechanisms are working? A) Arterial blood gas sampling indicates a pH in the range of 7.45 to 7.55. B) Her kidneys are likely to reabsorb H+ and secrete HCO3- C) Her body will produce excess metabolic CO2. D) Her kidneys will adapt with an increase in plasma HCO3- and her pH will decrease.
When preparing educational information regarding benign prostatic hyperplasia (BPH) for a group of older male patients, the nurse includes which of the following? (Select all that apply.)
a. Eighty percent of males experience the symptoms by age 80. b. Diabetes mellitus is a risk factor. c. It is only as the prostate enlarges that symptoms occur. d. The resulting urinary retention can cause urinary tract infections. e. Symptoms are a result of urethral obstruc-tion.
A preschool child is recovering from cardiac surgery. The nurse would recommend which of the following toys:
a. Jump rope b. Large beads and string c. Skateboard d. Rocking horse
Which statement about aging provides the best rationale for focused assessment of older adult patients?
a. Older adults are often socially isolated and lonely. b. As people age, they become more rigid in their thinking. c. The majority of older adults sleep more than 12 hours per day. d. The senses of vision, hearing, touch, taste, and smell decline with age.