A nurse is caring for a client who has an acute respiratory illness. For which of the following manifestations of an airway obstruction should the nurse monitor? (Select all that apply.)
Inspiratory stridor
Nausea
Retractions
Muscle tremors
Cyanosis
Correct Answer : A,C,E
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration that indicates partial obstruction of the upper airway. It is a characteristic sign of airway obstruction and requires immediate attention.
B. Nausea
Nausea is not a common manifestation of airway obstruction. It may be associated with other conditions such as gastrointestinal issues or medication side effects but is not directly related to airway obstruction.
C. Retractions
Retractions refer to visible sinking of the skin between the ribs and above the clavicles during inspiration, which indicates increased effort to breathe. Retractions can occur in response to airway obstruction, as the body attempts to overcome the resistance to breathing.
D. Muscle tremors
Muscle tremors are not specific manifestations of airway obstruction. Tremors may occur due to various reasons such as anxiety, electrolyte imbalances, or neurological conditions but are not typically associated with airway obstruction.
E. Cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It can occur with airway obstruction as oxygen exchange is compromised. Cyanosis is a late sign of respiratory distress and requires immediate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Dyspnea: Dyspneais a hallmark symptom of emphysema. As lung function deteriorates, the client experiences difficulty breathing, especially during exertion, due to reduced gas exchange and air trapping in the lungs.
B. Barrel chest:A barrel chest is a common finding in emphysema due to hyperinflation of the lungs over time. This causes the chest to become rounded and expands the anterior-posterior diameter of the thorax.
C. Clubbing of the fingers: Clubbing of the fingers is not a typical finding in emphysema or COPD. It is more commonly associated with conditions like lung cancer, cystic fibrosis, or congenital heart disease, where chronic severe hypoxia is present.
D. Shallow respirations:Clients with emphysema often exhibit shallow respirations as their lung elasticity decreases, making it difficult to fully exhale. As a result, breathing may become more rapid and shallow to compensate for poor oxygen exchange.
E. Bradycardia: Bradycardiais not typically associated with emphysema. Instead, clients with chronic respiratory conditions like emphysema may experience tachycardiaas the body tries to compensate for low oxygen levels.
Correct Answer is B
Explanation
First, we need to find out how many milligrams (mg) are in 1 milliliter (mL) of the available diphenhydramine solution:
12.5 mg/5 mL
To find out how many milligrams are in 1 mL, we divide the total milligrams by the total milliliters:
12.5 mg ÷ 5 mL = 2.5 mg/mL
Now that we know the concentration of diphenhydramine is 2.5 mg/mL, we can calculate the dose needed for the order of 25 mg:
25 mg ÷ 2.5 mg/mL = 10 mL
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