Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?
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Solution
“I should put on the stockings before getting out of bed in the morning."
Option D: Promote venous return by applying external pressure on veins.
Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?
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Solution
2.4 ml
Option B: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.
Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?
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Solution
21
Option B: 3000 x 10 divided by 24 x 60.
After a motor vehicle accident, Armand a 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?
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Solution
Air leak
Option A: Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space.
Options B and C: Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.
Alvin with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?
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Solution
Respiratory alkalosis
Option D: A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.
Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?
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Solution
Alveolar damage in the infarcted area
Option A: The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts.
Option B: Clot formation usually occurs in the legs.
Options C and D: There’s a loss of lung parenchyma and subsequent scar tissue formation.
If a client requires a pneumonectomy, what fills the area of the thoracic cavity?
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Solution
Serous fluids fill the space and consolidate the region
Option C: Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung.
Option A: Air can’t be left in the space.
Option B: There’s no gel that can be placed in the pleural space.
Option D: The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until space is filled.
A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?
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Solution
Pneumothorax
Options A, B, and D: From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.
A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?
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Solution
Spontaneous pneumothorax
Option D: A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath.
Options A and B: An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi.
Option C: Pneumonia would have bronchial breath sounds over the area of consolidation.