KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

Crackles to Bilateral lobes

Tenting skin and wet mucous membranes

C Tachycardia and hypotension

+4 edema to bilateral lower extremities and confusion

Answer and Explanation

The Correct Answer is C

Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with ﬂuid overload, but not with dehydration.

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Correct Answer is C

Explanation

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

A. Rales B. Crackles C. Rhonchi D. Stridor

Correct Answer is B

Explanation

Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with ﬂuid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.

Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.

Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.

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KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

Correct Answer is C

Explanation

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

Correct Answer is B

Explanation

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