A nurse is caring for a client who has a pneumothorax.

Exhibits

For each potential provider's order, click to specify if the potential order is anticipated, non-essential, or contraindicated for the client.

Thoracentesis

Prepare for insertion of a chest tube.

Pulmonary Function Tests (PFTS)

Obtain intravenous access.

Obtain ABGS.

Answer and Explanation

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

Thoracentesis is non-essential for a client with pneumothorax because it is primarily used to drain fluid accumulation, not air. Unless there is a suspicion of a hemothorax or fluid build-up, thoracentesis would not address the cause of the client's respiratory distress and would not be the initial intervention.

Prepare for insertion of a chest tube is anticipated because it is the standard treatment for pneumothorax. A chest tube allows continuous evacuation of air from the pleural space, promoting lung re-expansion and stabilizing breathing, which is urgently needed for clients who report severe dyspnea and shallow respirations.

Pulmonary Function Tests (PFTs) are contraindicated because they involve deep inhalation and forceful exhalation maneuvers, which could cause further lung collapse or exacerbate the pneumothorax. These tests are inappropriate during acute respiratory distress and must be deferred until the pneumothorax resolves.

Obtaining intravenous access is anticipated because having a reliable IV line ensures immediate access for emergency medications, fluids, sedation, and possible analgesia, particularly when preparing for procedures such as chest tube insertion or stabilizing hemodynamic status in case of deterioration.

Obtain ABGs is anticipated because arterial blood gases provide critical information about the client's respiratory efficiency, including oxygenation, ventilation, and acid-base balance. These results help guide the need for supplemental oxygen therapy, ventilatory support, or further interventions.

Nursing Test Bank

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Correct Answer is ["5"]

Explanation

Calculation:

Convert the client's weight from pounds (lbs) to kilograms (kg):

Conversion factor: 1 kg = 2.2 lbs
Formula: Weight in kg = Weight in lbs / 2.2 lbs/kg

= 150 lbs / 2.2 lbs/kg

≈ 68.18 kg

Calculate the milligrams of pancuronium per hour:

Ordered dose: 0.07 mg/kg/hr
Client's weight in kg: ≈ 68.18 kg
Formula: Dosage per hour (mg/hr) = Ordered dose (mg/kg/hr) × Client's weight (kg)

= 0.07 mg/kg/hr × 68.18 kg

≈ 4.7726 mg/hr

Round the result to the nearest whole number:

mg/hr rounded to the nearest whole number is 5 mg/hr.

A. Use of heat lamp for warmth B. Removal of wet clothing C. Increasing the room temperature D. Administration of cold intravenous fluids

Correct Answer is D

Explanation

A. Use of heat lamp for warmth can be beneficial if used carefully to gently rewarm affected areas. However, direct intense heat should be avoided to prevent burns or uneven warming; controlled external heat sources can assist in stabilizing the client’s temperature when monitored properly.
B. Removal of wet clothing is crucial because wet garments accelerate heat loss through evaporation and conduction. Replacing wet clothing with dry, insulated materials is a priority in preventing further cooling and stabilizing the client's core temperature.
C. Increasing the room temperature is an appropriate and supportive intervention to create a warm environment, helping reduce further heat loss and assisting in the gradual rewarming process of a client suffering from hypothermia or frostbite injuries.
D. Administration of cold intravenous fluids is contraindicated because it would worsen hypothermia by introducing additional cold into the circulatory system. Warmed intravenous fluids should be administered instead to assist with core rewarming and prevent cardiac complications.

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A nurse is caring for a client who has a pneumothorax. Exhibits For each potential provider's order, click to specify if the potential order is anticipated, non-essential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is received orders to continue neuromuscular blockade on a 150 lbs client with ARDS. The pancuronium is ordered at 0.07 mg/kg/hr and to titrate per parameters. How many milligrams per hour will the nurse set the IV pump to? (Round to the nearest whole number.)

Correct Answer is ["5"]

Explanation

A nurse is caring for a client who sustained frostbite injuries after being found stranded on a snowy hiking trail. Which of the following interventions is contraindicated in preventing hypothermia?

Correct Answer is D

Explanation

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A nurse is caring for a client who has a pneumothorax.

Exhibits

For each potential provider's order, click to specify if the potential order is anticipated, non-essential, or contraindicated for the client.