NCLEX-PN Quiz
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PHYSIOLOGICAL ADAPTATION
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A 72-year-old client with a long-term tracheostomy for neuromuscular disease is on a medical-surgical unit. The nurse finds the client anxious with labored breathing; the tracheostomy tube appears partially out of the stoma. Vital signs: heart rate 124/min, respiratory rate 32/min, blood pressure 168/90 mm Hg, oxygen saturation 86%. Which assessment finding requires IMMEDIATE intervention?
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