RN VATI ADULT MEDICAL SURGICAL 2021

A client who has a tension pneumothorax can have tracheal deviation with dyspnea, tachycardia, and tachypnea. On auscultation, breath sounds over the area of the pneumothorax are decreased or absent. However, tracheal de ...

A client who has a tension pneumothorax can have tracheal deviation with dyspnea, tachycardia, and tachypnea. On auscultation, breath sounds over the area of the pneumothorax are decreased or absent. However, tracheal deviation is not a manifestation of ARDS. Refractory hypoxemia MY ANSWER ARDS is a systemic inflammatory response to trauma, sepsis, burns, pancreatitis, and blood transfusions, when excess lung fluid dilutes surfactant activity in the lungs. A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS. Bloody expectorant when coughing A client who has lung cancer or laryngeal trauma can have hemoptysis. However, bloody expectorant is not a manifestation of ARDS. • RN VATI Adult Medical Surgical 2019 CLOSE Question 81 loaded rationals provided Question: 81 of 90 CORRECT • Time Remaining: 00:36:33 • Pause Remaining: 00:05:00 PAUSE FLAG An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus? Coughing Status asthmaticus causes labored breathing and wheezing. Coughing indicates that the client is exchanging air and is a manifestation of pneumonia, not status asthmaticus. Flat neck veins A client who has status asthmaticus has distended neck veins while trying to facilitate breathing due to increased pulmonary pressure. Use of accessory muscles MY ANSWER A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen. Presence of coarse crackles The presence of coarse crackles indicates air movement through fluid-filled airways and is a manifestation of pneumonia, not status asthmaticus. • RN VATI Adult Medical Surgical 2019 CLOSE Question 80 loaded rationals provided Question: 80 of 90 CORRECT • Time Remaining: 00:36:27 • Pause Remaining: 00:05:00 PAUSE FLAG A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider? Tender, bleeding gums Gingival hyperplasia is an overgrowth of gum tissue that causes the gums to bleed, swell, and become tender. Gingival hyperplasia is nonurgent adverse effect when a client is taking phenytoin; therefore, there is another finding that is the priority. The nurse should advise the client to maintain good oral hygiene with a soft toothbrush and to follow up with an oral health professional. Increased facial hair Hirsutism, an increased growth of hair in unexpected places on the client's body, is nonurgent because it is an expected finding for a client who is taking phenytoin. Constipation Constipation is nonurgent because it is an expected finding for a client who is taking phenytoin. Skin rash MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a rash, which can have a measles-like appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should report this finding to the provider immediately.