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  • A nurse is assessing a client whi is experiencing shortness of breath. The client exhibits nasal flaring, use of accesory muscles, a respiratory rate of 36 breaths per minute, and an oxygen...
    A nurse is assessing a client whi is experiencing shortness of breath. The client exhibits nasal flaring, use of accesory muscles, a respiratory rate of 36 breaths per minute, and an oxygen...
    Notify the clients physician. Check the position of the nasal cannula

  • What should the nurse plan to do if the chest drainage system is accidentally disconnected? A nurse is caring for a client with a chest tube.
    What should the nurse plan to do if the chest drainage system is accidentally disconnected? A nurse is caring for a client with a chest tube.
    1. place the end of the chest tube in a container of sterile saline.-rationale: if a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. the nurse should apply an occlusive dressing if the chest tube is pulled out not if the system is disconnected. the nurse shouldnt clamp the chest tube because clamping increases the risk of tension pneumothorax. the nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.client needs category: physiological integrityclient needs subcategory: reduction of risk potentialcognitive level: applicationreference: smeltzer, s.c., et al. brunner & suddarths textbook of medical-surgical nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 761.

  • What is the purpose of defibrillation?
    What is the purpose of defibrillation?
    Defibrillation is a method used when a person undergoing a cardiac arrest experiences Ventricular Fibrillation. It involves giving a minor electric shock to the patient by placing two pads, one above the right nipple and the other below the heart on the left roughly diagonal to each other.(Image provided) Ventricular fibrillation is the disorganized contraction of heart ventricles which make the heart shake instead of pumping the blood. It's a sort of cardiac arrhythmia and happens in a lot of heart attack cases. The shock depolarizes the entire electrical conduction system of the heart and the naturally present pacemaker cell can repolarize and try to assert the normal resumption of the heartbeat

  • What is the rationale for these interventions? A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical...
    What is the rationale for these interventions? A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical...
    1. they help prevent cardiac arrhythmias.-rationale: et suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isnt a complication associated with suctioning. hyperventilation and hyperoxygenation cant prevent a pneumothorax because this condition itself indicates air in the pleural space. pulmonary edema is associated with cardiac dysfunction, not et suctioning.client needs category: physiological integrityclient needs subcategory: reduction of risk potentialcognitive level: applicationreference: smeltzer, s.c., et al. brunner & suddarths textbook of medical-surgical nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 737.

  • How should the nurse ascertain the best position to facilitate clearing the lungs while she prepares to perform postural drainage?
    How should the nurse ascertain the best position to facilitate clearing the lungs while she prepares to perform postural drainage?
    The correct answer to this question is that the nurse should perform auscultation on the patient. Auscultation is a procedure which involves listening to the sounds of the body. The sounds listened to are internal. A stethoscope is used to listen to these sounds. The purpose of listening to these sounds is to be able to diagnose a disease. Auscultation can also be used to examine respiratory and gastrointestinal systems. It is essential for the physician performing the procedure to have excellent listening skills and to be skillful in locating the sounds they need to listen to. French physician Rene Laennec developed this concept with his invention of the stethoscope.

  • Which is a sign or symptom of theophylline toxicity?
    Which is a sign or symptom of theophylline toxicity?
    1. nausea-rationale: theophylline toxicity causes gi disturbances, such as nausea, vomiting, abdominal cramps, epigastric pain, anorexia, or diarrhea. it also produces central nervous system reactions, including headache, irritability, restlessness, anxiety, insomnia, and dizziness (rarely). however, theophylline toxicity doesnt result in bradycardia, constipation, or dysuria.client needs category: physiological integrityclient needs subcategory: pharmacological and parenteral therapiescognitive level: analysisreference: springhouse nurses drug guide 2007. philadelphia: lippincott williams & wilkins, 2007, p. 1225.

  • Which statements about the course of cystic fibrosis are true? A nurse is caring for a 17-year-old female with cystic fibrosis who has been admitted to the hospital to receive I.V. antibiotic and...
    Which statements about the course of cystic fibrosis are true? A nurse is caring for a 17-year-old female with cystic fibrosis who has been admitted to the hospital to receive I.V. antibiotic and...
    Breast development is commonly delayed-2. the adolescent is at risk for developing diabetes-3. normal sexual relationships can be expected-cystic fibrosis delays growth and the onset of puberty. children with cystic fibrosis tend to be smaller that average size and develop secondary sex characteristics later in life. in addition, children with cf are at risk for developing diabetes mellitus because the pancreatic duct becomes obstructed as pancreatic tissues are destroyed. people with cf can expect to have normal sexual relationships, but fertility becomes difficult because thick secretions obstruct the cervix and block sperm entry. males and females carry the gene for cystic fibrosis. pulmonary disease commonly progresses as the child ages, requiring additional respiratory treatment - not less.

  • What is the most common invader of the nasopharynx?
    What is the most common invader of the nasopharynx?
    The most common invaders of the nasopharynx are viruses. The pharynx is a part of the throat which lays behind the nasal cavity and the mouth. It is above the larynx and the esophagus. Even though the structure of pharynx is not the same among the invertebrates and the vertebrates, it is found in most species. In the human body, the pharynx is considered to be a part of the digestive system. Furthermore, it is also considered as the conducting zone of the respiratory system. Two sets of pharyngeal muscles are responsible for the formation of the pharynx in humans.

  • How much of your blood passes through your kidneys each day?
    How much of your blood passes through your kidneys each day?
    Your kidney blood passes through about 425 gallons or 1609 liters each day.

  • A 10 year old with a history of asthma is diagnosed with status asthmaticus. This child:
    A 10 year old with a history of asthma is diagnosed with status asthmaticus. This child:
    A patient can have severe wheezing while in status asthmaticus. Loss of wheezing is a sign of impending respiratory failure, the final stage of status asthmaticus. Both A and B are correct answeres in this question. Patients fail to respond to treatment for asthma exacerbation, but can still have severe wheezing with diminished aeration of the lungs.

  • What should the nurse expect in the following case?
    What should the nurse expect in the following case?
    Option D - A drop in the client's heart rate is correct. This what the nurse should expect as the vasovagal response. Stimulation of the vague nerve in the pharynx causes the vasovagal response. Stimulation of the vague nerve is known to cause parasympathetic responses in certain parts of the body. It increases gastric gastric secretion, constrict the pupil and cause bronchoconstriction. Option A - The client's pupils will become dilated is wrong because the pupils become constricted in vasovagal response Option B- The client is experiencing bronchodilation is wrong vasovagal response causes bronchoconstriction. Option C - A decrease in the client's gastric secretions is wrong because gastric secretions increases in vasovagal response.

  • What is the nurse's most appropriate action in the following? A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate...
    What is the nurse's most appropriate action in the following? A client with chronic obstructive pulmonary disease tells a nurse that he feels short of breath. The client's respiratory rate...
    1. give the nebulizer treatment herself.-rationale: the clients needs are preeminent, so the nurse should administer the nebulizer treatment immediately. the nurse can deal with the respiratory therapists lack of response after the clients condition is stabilized. there is no need to involve the physician in personnel issues. staying with the client is important, but it isnt a substitute for administering the needed bronchodilator. the order is for a nebulizer treatment not a metered-dose inhaler, so the nurse cant change the route without a new order from the physician.client needs category: safe, effective care environmentclient needs subcategory: management of carecognitive level: analysisreference: smeltzer, s.c., et al. brunner & suddarths textbook of medical-surgical nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 697.

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