Medsurg Proctored Exams preparations week1-5

Oxygenation 1-A nurse is conducting a primary survey of a client who has sustained lifethreatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) ANSWERS - Ordered Response Correct 1) Open the airway using a jaw-thrust maneuver. 2) Determine effectiveness of ventilator efforts. 3) Establish IV access. 4) Perform a Glasgow Coma Scale assessment. 5) Remove clothing for a thorough assessment. 2-A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) ANSWERS - Multiple Response Select All That Apply 1) Dyspnea 2) Bradycardia 3) Barrel chest 4) Clubbing of the fingers 5) Deep respirations Answer Rationale: Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues.Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients.Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.Deep respirations is