Nokea
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
- A. Cor pulmonale
- B. Atelectasis
- C. Pulmonary embolus
- D. Cardiac tamponade
Correct Answer: B
Rationale: No breath sounds in the lower-right base postoperative suggest atelectasis, a lung collapse common after surgery, causing dyspnea and tachypnea.
You may also like to solve these questions
A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct Answer: B
Rationale: A client taking an MAO Inhibitor, such as phenelzine (Nardil), should avoid tyramine-rich foods, which includes avocados, bananas, and salami.
The parent of the adolescent taking chlordiazepoxide for the past 2 months telephones the nurse requesting to have the dose increased. The parent states, “Chlordiazepoxide is being given as directed, but my child's anxiety is increasing.†Which should be the nurse's best interpretation of this situation?
- A. The client may be developing tolerance to chlordiazepoxide and needs the dose reevaluated.
- B. The client may be skipping drug doses when not anxious and now needs the dose doubled.
- C. The client is becoming resistant to the drug effects, and an alternative medication is needed.
- D. The client's anxiety may be hormone-related, and larger doses of chlordiazepoxide are needed.
Correct Answer: A
Rationale: The client is describing tolerance, a sign of dependence, to chlordiazepoxide (Librium), and the dose needs reevaluation.
An allergic reaction is classified as what type of pharmacological effect?
- A. a therapeutic effect
- B. a side effect
- C. an adverse effect
- D. an incompatibility
Correct Answer: C
Rationale: An allergic reaction is considered an adverse effect, as it is unintended and requires treatment. A side effect is also undesired but is somewhat expected, and a side effect does not require intervention.
The nurse receives the HCP order to start TPN for the client who has a PICC. Into which type of catheter illustrated should the nurse plan to administer the TPN?
- A. TPN_1.PNG
- B. TPN_2.PNG
- C. TPN_3.PNG
- D. TPN_4.PNG
Correct Answer: B
Rationale: A: Illustration A is a central line that is percutaneously inserted into the jugular or subclavian vein and terminates in the central circulation. These are intended for short-term venous access. B: Illustration B is a PICC, which is inserted into the arm and terminates in the central circulation. A PICC is used when medications or solutions are too caustic to be peripherally administered or when therapy lasts more than 2 weeks. C: Illustration C is a tunneled catheter inserted into the upper chest wall and threaded through the cephalic vein; it terminates in the central circulation. D: Illustration D is an intra-aortic balloon pump catheter that is inserted into the femoral artery and positioned in the descending aortic arch. The balloon on the end inflates during diastole. It is not used for medication or fluid administration.
The nurse is evaluating the effectiveness of lispro and glargine insulins being administered to the 2-year-old with type 1 DM. Which findings on the serum laboratory report indicate that treatment is effective?
- A. Blood glucose
- B. Hgb A1c
- C. Creatinine
- D. WBCs
Correct Answer: A, B
Rationale: The treatment goal for children with type 1 DM is blood glucose levels within the normal range (60-105 mg/dL for a 2-year-old). Hgb A1c levels are indicative of the average blood glucose levels over the past 2 to 3 months; normal A1c is 3.9% to 7.7%. Although the other laboratory values are normal, these do not indicate the effectiveness of insulin therapy.