eaq adh2
What is the correct order of nursing interventions while assessing airway with simultaneous cervical spine stabilization?
Answer: 1. Open airway 2. Use jaw thrust maneuver 3. Insert oropharyngeal or nasopharyngeal airway, endotracheal tube, cricoidthyroidectomy 4. Immobilize patient
What is the primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system? 1. Ensure maintenance of the closed system 2.Maintain mechanical suction to the system 3.Encourage the client to deep breathe and cough 4.Keep the client in the dorsal recumbent position
Correct Answer: 1 Rationale : An airtight system is needed to reestablish negative pressure and to reinflate the lung. Drainage can be maintained without mechanical suction. Encouraging coughing and deep breathing is important, but not the priority. Any position is acceptable as long as the tube is not compressed or pulled.
An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? 1. Chlorpheniramine needs to be stopped immediately 2. These are common side effects of chlorpheniramine 3. Hydroxyzine needs to be taken with chlorpheniramine 4. The chlorpheniramine prescription needs to be changed
Correct Answer: 2
A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? 1. Tidal 2. Residual 3. Vital Capacity 4. Inspiratory Reserve
Correct Answer: 2 Rationale: The residual volume is the amount of air remaining in the lungs after maximum exhalation. Usually tidal, vital capacity, and inspiratory reserve volumes are under the individual's control. The force exerted by the abdominal thrust [1] [2] surpasses that which the individual is voluntarily capable of exerting.
What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? 1. Contains many small bubbles 2. Bubbles vigorously upon inspiration 3. Rises with inspiration and falls with expiration 4. Remains at a consistent level during the respiratory cycle
Correct Answer: 3 Rationale: During inspiration, negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration, negative pressure in the pleural space decreases, causing fluid to drop in the chamber. If the system is closed to the atmosphere, as it should be, bubbles will not be present. Changes in intrapleural pressure cause fluid to rise on inspiration and fall on expiration (tidaling).
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? 1. report of pain when taking deep breaths 2. client is observed splinting the fractured site 3. diminished breath sounds on the affected side 4. bowel sounds are auscultated in the lower chest
Correct Answer: 3 Rationale: Fractured ribs may penetrate the pleura and lung, allowing air to fill the pleural space and collapse the lung, causing diminished breath sounds. This is a complication of fractured ribs. Reports of pain when taking deep breaths is an expected response to tissue trauma caused by a fractured rib. Observing the client splinting the fracture site is an expected response to tissue trauma caused by a fractured rib. Bowel sounds auscultated in the lower chest suggest rupture of the diaphragm, not fractured ribs.
A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? 1. Change in level of consciousness 2 Increased pain 3. Increase in respiration 4. decreased heart rate
Correct Answer: 3 Rationale: Naloxone is given for decreased respirations caused by opioid overdose [1] [2]. The amount given is determined by the respiratory status, not the level of consciousness. Undesirable side effects of naloxone are pain and rapid heart rate with dysrhythmias.
