A client in the intensive care unit is receiving teaching before removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

Correct Answer: C

Rationale: The correct answer is C: Avoid speaking for extended periods. This instruction is important to prevent strain on the vocal cords and reduce the risk of aspiration or airway irritation post-extubation. Speaking after the removal of the endotracheal tube can potentially lead to complications. Step-by-step rationale: 1. Speaking can cause strain on the vocal cords, which may lead to hoarseness or damage. 2. It is essential to allow the airway to recover and prevent irritation or inflammation. 3. Resting the voice can aid in the healing process and reduce the risk of complications. 4. Incentive spirometer use (option B) is important for lung expansion but not directly related to vocal cord rest. 5. Vital signs monitoring (option D) is crucial but does not address vocal cord care or prevention of complications. 6. Resting in a side-lying position (option A) is not directly related to vocal cord rest or post-extubation care.

Correct Answer: B

Rationale: The correct answer is B: Nausea. In acute respiratory failure (ARF), the body may compensate by increasing respiratory rate, leading to respiratory alkalosis. This can cause nausea due to the altered pH levels affecting the chemoreceptors in the brain. Severe dyspnea (choice A) is a common symptom of ARF but does not specifically relate to nausea. Decreased level of consciousness (choice C) may indicate severe hypoxemia but is not a direct manifestation of ARF. Headache (choice D) is more commonly associated with conditions like hypoxia, hypercapnia, or respiratory acidosis in ARF.

Correct Answer: B

Rationale: The correct answer is B: Resonance. When assessing a client with chronic bronchitis, the healthcare provider should expect to hear resonant percussion sounds. This is because chronic bronchitis is characterized by inflammation and excess mucus production in the bronchial tubes, leading to airway obstruction. Resonance indicates normal lung tissue and air-filled spaces. Dullness (A) may suggest consolidation or fluid in the lungs, which is not typically associated with chronic bronchitis. Tympany (C) is a drum-like sound that can be heard over air-filled structures like the stomach, not typically expected in a lung assessment. Flatness (D) is heard over solid structures like the liver and would not be expected in a lung assessment for chronic bronchitis.

Correct Answer: D

Rationale: The correct answer is D because the student being in the yellow zone indicates moderate symptoms, not severe enough to necessitate hospitalization. A: Using a quick-relief inhaler is appropriate for yellow zone symptoms. B: Yellow zone indicates asthma is not well controlled, supporting the need for action. C: Peak flow of 50% to 80% signals a reduction in lung function, requiring intervention but not immediate hospitalization. Thus, D is the incorrect choice because hospitalization is not warranted for yellow zone symptoms.

Correct Answer: C

Rationale: Step 1: Pneumonia in older adults often presents with atypical symptoms. Step 2: Confusion is a common manifestation due to decreased oxygen levels. Step 3: Respiratory illness can lead to hypoxia, causing confusion. Step 4: Bradycardia, night sweats, and narrowed pulse pressure are not typical manifestations of pneumonia in older adults.