Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Rhonchi in the right lung

Symmetric chest expansion

Oxygen saturation greater than 949%

PaCO2 55 mm Hg on a blood gas

Client ambulates without shortness of breath

Diminished breath sounds in the right lung

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

A. Rhonchi are abnormal breath sounds that indicate the presence of mucus or fluid in the airways. Finding rhonchi in the right lung suggests the presence of respiratory congestion or obstruction, which may indicate ineffective treatment or ongoing respiratory issues.

B. Symmetric chest expansion indicates equal and adequate movement of both sides of the chest during inhalation. This finding suggests that there are no restrictions or abnormalities in the chest wall or lung tissue, which is indicative of effective treatment.

C. Oxygen saturation greater than 94% indicates adequate oxygenation of the blood, which is a positive indicator of effective treatment, particularly in clients with respiratory issues such as pneumonia or COPD.

D. A PaCO2 level of 55 mm Hg indicates hypercapnia, which is an elevated level of carbon dioxide in the blood. This finding suggests inadequate ventilation or respiratory failure, indicating ineffective treatment.

E. The ability to ambulate without experiencing shortness of breath suggests improved respiratory function and effective treatment, as it indicates adequate oxygenation and ventilation.

F. Diminished breath sounds suggest reduced airflow or lung volume in the affected area. This finding may indicate ongoing respiratory issues or incomplete resolution of the condition, suggesting ineffective treatment.

Nursing Test Bank

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Correct Answer is C

Explanation

C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.

A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.

B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority

D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.

A. Hyperventilation is eliminating carbon dioxide rapidly. B. Blood oxygen levels are stimulating the respiratory rate. C. Carbon dioxide is converted in the kidneys for elimination. D. High levels of carbon dioxide have accumulated in the blood.

Correct Answer is D

Explanation

D. Respiratory acidosis occurs when there is inadequate alveolar ventilation, leading to retention of carbon dioxide (hypercapnia) in the blood. The accumulation of carbon dioxide results in an increase in the partial pressure of carbon dioxide (PaCO2), leading to respiratory acidosis.

A. Hyperventilation refers to breathing at a rate and depth that exceeds the body's metabolic needs, leading to a decrease in the partial pressure of carbon dioxide (PaCO2) in the blood. Respiratory acidosis, however, is characterized by an increase in PaCO2 due to inadequate ventilation, not rapid elimination of carbon dioxide.

B. This choice refers to the hypoxic drive, which is a compensatory mechanism triggered by low oxygen levels in the blood. While hypoxemia (low oxygen levels) can stimulate the respiratory rate, it typically occurs in chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD) rather than acute respiratory acidosis.

C. While the kidneys play a role in regulating acid-base balance through the excretion of hydrogen ions and reabsorption of bicarbonate ions, they do not directly eliminate carbon dioxide from the body.

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Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

Correct Answer is D

Explanation

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products to help coat and protect the duodenal ulcer. Which is the best follow- up action by the nurse?

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the lies of the tracheostomy tube, which action is most important for the nurse to take?

Patient Data

Exhibits

Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings