A nurse auscultates a harsh hollow sound over a client's trachea ...

[drink]

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?
 
  a. Document the findings.
  b. Administer oxygen therapy.
  c. Position the client in high-Fowler's position.
  d. Administer prescribed albuterol.

Question 2

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?
 
  a. Administer an albuterol treatment.
  b. Notify the Rapid Response Team.
  c. Assess the client's peripheral pulses.
  d. Obtain blood and sputum cultures.

[joewallace]

Answer to Question 1

ANS: A
Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.

Answer to Question 2

ANS: B
Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

[drink]

Wow, this really help

[jackie]

Excellent