What assessment findings would indicate a client is suffering from an open traumatic
pneumothorax?
a. Tracheal deviation towards the affected side.
b. Sucking sound with respirations.
c. Decreased breath sounds on the affected side.
d. Distended neck veins.
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b. Sucking sound with respirations.
Rationale: Open traumatic pneumothorax would cause a sucking sounds
with breathing. Tracheal deviation and distended neck veins indicate
tension pneumothorax. Breath sounds would be absent not diminished.
Which client would the nurse most question an order for a hypertonic solution?
a. A 20 year old client with severe fluid volume deficit
b. A 40 year-old client with a sodium level of 120 mEq/L.
, c. A 60 year-old client with a history of congestive heart failure
d. A 50 year-old client with a hemorrhage and blood pressure of 70/50 mm Hg
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c. A 60 year-old client with a history of congestive heart failure
Interpret the following ABGs of pH 7.55, PaCO2 45 mm Hg, HCO3 30:
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
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a. Metabolic alkalosis
The nurse is caring for a client on positive pressure mechanical ventilation via an
endotracheal (ET) tube when the volume (low pressure) alarm goes off on the
ventilator. What should the nurse do first?
a. Suction the client
b. Request a chest x-ray to assess placement
c. Check all tubing and connections
d. Increase the FiO2 and flow rate
Give this one a try later!
pneumothorax?
a. Tracheal deviation towards the affected side.
b. Sucking sound with respirations.
c. Decreased breath sounds on the affected side.
d. Distended neck veins.
Give this one a try later!
b. Sucking sound with respirations.
Rationale: Open traumatic pneumothorax would cause a sucking sounds
with breathing. Tracheal deviation and distended neck veins indicate
tension pneumothorax. Breath sounds would be absent not diminished.
Which client would the nurse most question an order for a hypertonic solution?
a. A 20 year old client with severe fluid volume deficit
b. A 40 year-old client with a sodium level of 120 mEq/L.
, c. A 60 year-old client with a history of congestive heart failure
d. A 50 year-old client with a hemorrhage and blood pressure of 70/50 mm Hg
Give this one a try later!
c. A 60 year-old client with a history of congestive heart failure
Interpret the following ABGs of pH 7.55, PaCO2 45 mm Hg, HCO3 30:
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Respiratory acidosis
Give this one a try later!
a. Metabolic alkalosis
The nurse is caring for a client on positive pressure mechanical ventilation via an
endotracheal (ET) tube when the volume (low pressure) alarm goes off on the
ventilator. What should the nurse do first?
a. Suction the client
b. Request a chest x-ray to assess placement
c. Check all tubing and connections
d. Increase the FiO2 and flow rate
Give this one a try later!
