A healthcare provider is assessing a client immediately after the removal of the endotracheal tube. Which of the following findings should the provider report to the healthcare provider?

Correct Answer: A

Rationale: The correct answer is A: Stridor. Stridor is a high-pitched, harsh respiratory sound that indicates airway obstruction, which can be life-threatening post endotracheal tube removal. Copious oral secretions (B), hoarseness (C), and sore throat (D) are common after endotracheal tube removal but do not indicate immediate airway compromise. Reporting stridor is crucial for prompt intervention to prevent respiratory distress.

Correct Answer: A

Rationale: The correct answer is A: Loud, scratchy sounds. Pleurisy is inflammation of the pleura, causing friction between layers of the lung lining, resulting in loud, scratchy sounds known as pleural friction rubs. Squeaky, musical sounds (B) are indicative of wheezing in conditions like asthma. Popping sounds (C) can be heard in conditions like atelectasis or pneumonia. Snoring sounds (D) are typically associated with upper airway obstruction, not pleurisy. Therefore, in the context of pleurisy, the healthcare professional should expect to hear loud, scratchy sounds during auscultation.

Correct Answer: A

Rationale: The correct answer is A: Provide the client with supplemental oxygen at 5 L/min via facemask. In cardiogenic pulmonary edema, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress, reducing the workload on the heart. This intervention addresses the client's dyspnea and anxiousness by improving oxygen delivery. Choice B is incorrect as placing the client in high-Fowler's position with legs in a dependent position can help with breathing but does not address the immediate need for oxygenation. Choice C is incorrect as sublingual nitroglycerin is typically used for angina and not the priority intervention for cardiogenic pulmonary edema. Choice D is incorrect as morphine sulfate IV may be indicated for pain relief and anxiety, but it is not the priority intervention to address the client's oxygenation needs in cardiogenic pulmonary edema.

Correct Answer: C

Rationale: The correct answer is C: Confirming the gag reflex. Immediately following a bronchoscopy, the nurse must prioritize confirming the gag reflex to ensure the client can protect their airway. This is crucial to prevent aspiration and respiratory complications. Observing for confusion (choice A) is important but not the priority in this situation. Auscultating breath sounds (choice B) is also important but confirming the gag reflex takes precedence. Measuring blood pressure (choice D) is not directly related to the immediate post-bronchoscopy monitoring.

Correct Answer: D

Rationale: The correct answer is D: Confusion. Confusion in an older adult with community-acquired pneumonia can indicate hypoxia or sepsis affecting the brain. It is a common manifestation in elderly patients with pneumonia due to impaired gas exchange and systemic inflammatory response. Unequal pupils do not typically relate to pneumonia. Hypertension is not a common finding in pneumonia; hypotension is more likely. Tympany upon chest percussion is associated with conditions like pneumothorax, not pneumonia. Therefore, confusion is the most relevant finding in this scenario.