The nurse is assessing a client who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

Correct Answer: D

Rationale: The correct answer is D because the inability to move the left arm could indicate a neurological deficit or stroke, which is a critical finding that requires immediate medical attention in a hypertensive emergency. This could indicate a potential life-threatening condition that needs urgent intervention to prevent further complications. A: Urine output is important but not as critical as potential neurological deficits in this scenario. B: Tremors in the fingers are concerning but not as urgent as a potential neurological deficit. C: Headache at level 7 is significant but not as critical as a neurological deficit that could indicate a stroke.

Correct Answer: C

Rationale: The correct answer is C: AECFA. This sequence represents the flow of air through the respiratory system. Airway resistance is primarily overcome by the contraction and relaxation of the smooth muscles in the airways. The correct sequence includes the airway segments that actively participate in regulating airway resistance - the trachea (A), bronchi (E), and bronchioles (C and F). The other choices do not include the correct segments that are involved in overcoming airway resistance.

Correct Answer: A

Rationale: The correct answer is A: pleura. The pleura is a two-layered membrane that covers the lungs. The outer layer is called the parietal pleura, which lines the chest wall, and the inner layer is called the visceral pleura, which covers the lungs themselves. This double-layered structure helps to protect and cushion the lungs during breathing movements. Summary of incorrect choices: B: The diaphragm is a dome-shaped muscle located below the lungs that plays a role in breathing but does not cover the lungs. C: The respiratory membrane refers to the interface where gas exchange occurs in the alveoli, not the covering of the lungs. D: The intercostal muscles are located between the ribs and assist in breathing but do not cover the lungs.

Correct Answer: B

Rationale: The correct initial nursing action is to choose option B: Grasp the retention sutures to spread the opening. This is because spreading the opening using the retention sutures can help maintain the airway patency until the tube is reinserted. Calling the physician (option A) or respiratory therapy department (option C) may cause delays in addressing the immediate airway obstruction. Covering the tracheostomy site with a sterile dressing (option D) does not address the primary concern of maintaining the airway. Therefore, option B is the most appropriate and effective action to take in this situation.

Correct Answer: A

Rationale: The correct answer is A: Auscultating the lungs for bilateral breath sounds. This is the most essential nursing action for a male client with an endotracheal tube because it ensures proper placement of the tube and adequate ventilation. By auscultating the lungs, the nurse can assess for any potential complications such as tube displacement, pneumothorax, or mucus plugging. This action helps in early detection of respiratory issues and prompt intervention if needed. Summary: - Choice B (Turning the client from side to side every 2 hours) is important for preventing pressure ulcers but not as critical as assessing breath sounds. - Choice C (Monitoring serial blood gas values every 4 hours) is important for evaluating respiratory status but does not provide immediate information on tube placement. - Choice D (Providing frequent oral hygiene) is important for preventing infections but does not directly assess the client's respiratory status with an ET tube.