A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Pneumothorax

Atelectasis

Flail chest

Hemothorax

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because a pneumothorax is a condition in which air enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.

Choice B Reason: This is incorrect because atelectasis is a condition in which alveoli collapse and cause reduced gas exchange. It does not cause the chest wall to move inward and outward paradoxically.

Choice C Reason: This is correct because ﬂail chest is a condition in which multiple ribs are fractured and cause a segment of the chest wall to detach from the rest of the thoracic cage. It causes the chest wall to move inward and outward paradoxically, as well as dyspnea and pain.

Choice D Reason: This is incorrect because a hemothorax is a condition in which blood enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.

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Correct Answer is ["100"]

Explanation

To estimate the percentage of body surface area burned using the Rule of Nines, follow these guidelines:

Head and Neck: 9%
Each Arm: 9% (right arm) + 9% (left arm) = 18%
Front of Torso: 18%
Back of Torso: 18%
Each Leg: 18% (right leg) + 18% (left leg) = 36%
Genital Area: 1%

Now, add up the percentages of the burned areas:

9% (head and neck) + 18% (each arm) + 18% (front of torso) + 18% (back of torso) + 36% (each leg) + 1% (genital area) = 100%

So, the nurse should estimate that the client has burned 100% of their body surface area.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Correct Answer is A

Explanation

Choice A Reason: This is correct because respiratory acidosis is characterized by a low pH and a high PaCO2, indicating that the client has impaired ventilation and excess carbon dioxide in the blood.

Choice B Reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2, indicating that the client has increased ventilation and reduced carbon dioxide in the blood.

Choice C Reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3, indicating that the client has an excess of metabolic acids or a loss of base in the blood.

Choice D Reason: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3, indicating that the client has an excess of base or a loss of metabolic acids in the blood.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 is 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base imbalances?

Correct Answer is A

Explanation

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

A nurse is monitoring the ﬂuid replacement of a client who has sustained burns. The nurse should administer which of the following ﬂuids in the first 24 hr following a burn injury?

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

A nurse is caring for a client 4 hr following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?