A nurse is assessing a client following the insertion of a central venous catheter.

Which of the following findings indicates a pneumothorax?

Distended neck veins.

Itching over the incision.

Irregular heart rate.

Diminished breath sounds.

Answer and Explanation

The Correct Answer is D

A pneumothorax is a collapsed lung that occurs when air leaks into the space between the lung and the chest wall.
This can cause diminished breath sounds on the affected side. Distended neck veins are not a symptom of pneumothorax.
B) Itching over the incision is not a symptom of pneumothorax.
C) Irregular heart rate is not a symptom of pneumothorax.

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Correct Answer is C

Explanation

“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.

A. 2.5 mL. B. 25 mL. C. 2.05 mL. D. 2.25 mL.

Correct Answer is A

Explanation

Let’s break down the problem step by step:

Step 1: Convert the client’s weight from pounds (lb) to kilograms (kg). We know that 1 kg = 2.2 lbs. So, we have: 220 lb ÷ 2.2 = 100 kg

Step 2: Calculate the total amount of naloxone needed. The doctor ordered 10 mcg/kg, and the client weighs 100 kg. So, we have: 10 mcg/kg × 100 kg = 1000 mcg

Step 3: Convert micrograms (mcg) to milligrams (mg). We know that 1 mg = 1000 mcg. So, we have: 1000 mcg ÷ 1000 = 1 mg

Step 4: Calculate the volume of naloxone solution needed. The available naloxone solution is 0.4 mg/mL. So, we have: 1 mg ÷ 0.4 = 2.5 mL

So, the nurse should administer 2.5 mL of naloxone. Since we are asked to round off to the nearest tenth, the final answer remains 2.5 mL.

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A nurse is assessing a client following the insertion of a central venous catheter. Which of the following findings indicates a pneumothorax?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following?

Correct Answer is C

Explanation

A nurse is preparing to administer naloxone 10 mcg/kg via IV bolus to a client who weighs 220 lb. The amount available is 0.4 mg/mL. How many mL should the nurse administer? (round off to the nearest tenth)

Correct Answer is A

Explanation

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A nurse is assessing a client following the insertion of a central venous catheter.

Which of the following findings indicates a pneumothorax?