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a nurse working in an ED is caring for a client following an
acute chest trauma.
which of the following findings should indicate to the nurse
that the client is
possibly experiencing a tension
pneumothorax?
A.) Collapsed neck veins on the affected side
B.) Collapsed neck veins on the unaffected side
C.) Tracheal deviation to the affected side
D.) Tracheal deviation to the unaffected side - ANSWER-
Tracheal deviation to the unaffected side
rationale:
The nurse should recognize that deviation of the trachea to the
unaffected side is a possible indicator that the client is
experiencing a tension pneumothorax. A tension pneumothorax
results from free air filling the chest cavity, causing the lung to
collapse and forcing the trachea to deviate to the unaffected
side.
,a nurse is caring for a client who's in respiratory distress.
which of the following low-flow delivery devices should the
nurse use to provide the client w/ highest level of oxygen?
A.) Nasal
cannula
B.) Nonrebreather
mask
C.) Simple face
mask
D.) Partial rebreather mask - ANSWER-
Nonrebreather mask
rationale:
The nurse should use a nonrebreather mask for a client who is
in respiratory distress to provide the highest oxygen level. A
nonrebreather mask is made up of a reservoir bag from which
the client obtains the oxygen, a one-way valve to prevent
exhaled air from entering the reservoir bag, and exhalation
ports with flaps that prevent room air from entering the mask.
This device delivers greater than 90% FiO2.
a nurse is planning care for a client who has asthma. which of
the following meds should the nurse plan to administer during
an acute asthma attack?
A.) cromolyn
sodium
, B.) prednisone
C.)
fluticasone/salmeterol
D.) albuterol - ANSWER-
Albuterol
rationale:
The nurse should administer albuterol because it acts quickly
to produce bronchodilation during an acute asthma attack.
a nurse is caring for a client who's in acute respiratory failure
and is receiving mechanical ventilation. which of the following
assessments is the best method
for the nurse to use to determine the effectiveness of the
current treatment
regimen?
A.)
BP
B.) Cap
refill
C.)
ABGs
D.) HR - ANSWER-Arterial blood
gases
rationale:
When using the airway, breathing, circulation approach to
client care, the nurse should place priority on evaluating