The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

Listening to at least one full respiration in each location.

Instructing the client to breathe in and out rapidly while listening to breath sounds.

Listening to breath sounds through the hospital gown or clothing.

Instructing the client to take slow deep breaths through his or her nose.

Listening as the client inhales, then goes to the next site during exhalation.

Answer and Explanation

Correct Answer : B,C

Choice A reason: Listening to at least one full respiration in each location is a proper technique for respiratory assessment. It ensures that the nurse can accurately assess the breath sounds and identify any abnormalities. This method allows for a thorough evaluation of the respiratory system, ensuring that no areas are missed.

Choice B reason: Instructing the client to breathe in and out rapidly while listening to breath sounds is incorrect. Rapid breathing can lead to hyperventilation and may not provide an accurate representation of the client’s normal breath sounds. The proper technique is to instruct the client to take slow, deep breaths through their mouth, which allows for a more accurate assessment of the breath sounds and any potential abnormalities.

Choice C reason: Listening to breath sounds through the hospital gown or clothing is incorrect. Clothing can interfere with the sounds and may lead to inaccurate assessments. The proper technique is to place the stethoscope directly on the client’s skin to ensure that the breath sounds are heard clearly and accurately.

Choice D reason: Instructing the client to take slow deep breaths through his or her nose is partially correct but not ideal. While slow deep breaths are appropriate, they should be taken through the mouth to ensure that the breath sounds are more pronounced and easier to assess. Breathing through the nose can sometimes muffle the sounds and make it harder to detect abnormalities.

Choice E reason: Listening as the client inhales and then moving to the next site during exhalation is incorrect. The nurse should listen to both the inhalation and exhalation phases of respiration at each site. This ensures a complete assessment of the breath sounds and helps in identifying any abnormalities that may be present during either phase of respiration.

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Correct Answer is C

Explanation

Choice A reason:

5% dextrose in water (D5W) is not typically used for fluid resuscitation in cases of hypovolemia due to severe bleeding. D5W is a hypotonic solution once the dextrose is metabolized, which means it does not remain in the intravascular space and is not effective in expanding blood volume. It is more commonly used for providing free water and calories.

Choice B reason:

5% dextrose in 0.25% sodium chloride (D5 1/4 NS) is also not suitable for fluid resuscitation in hypovolemia due to severe bleeding. This solution is hypotonic and will not adequately expand the intravascular volume. It is generally used for maintenance fluids rather than for resuscitation.

Choice C reason:

0.9% normal saline (0.9% NaCl) is the preferred choice for fluid resuscitation in hypovolemia due to severe bleeding. It is an isotonic solution, meaning it has the same osmolarity as blood and remains in the intravascular space, effectively expanding blood volume. This helps to restore circulating volume and improve tissue perfusion.

Choice D reason:

3% sodium chloride (3% NaCl) is a hypertonic solution and is not typically used for fluid resuscitation in hypovolemia due to severe bleeding. Hypertonic solutions can cause rapid shifts of fluid from the intracellular to the extracellular space, which can lead to complications such as hypernatremia and osmotic demyelination syndrome. It is generally reserved for specific situations such as severe hyponatremia.

Correct Answer is ["9.0"]

Explanation

Calculation and Answer

Step 1: Determine the total dose required per administration.

Dose required = 0.5 mg/kg × 90 kg
Dose required = 45 mg

Step 2: Determine the concentration of the drug.

Concentration = 25 mg per 5 mL

Step 3: Calculate the volume needed to administer the required dose.

Volume (mL) = Dose required ÷ Concentration
Volume (mL) = 45 mg ÷ (25 mg ÷ 5 mL)
Volume (mL) = 45 mg ÷ 5 mg/mL
Volume (mL) = 9 mL

The client will receive 9.0 mL per dose.

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The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

A client is admitted with hypovolemia due to severe bleeding. Which IV fluid does the nurse anticipate using to replace fluid losses?

Correct Answer is C

Explanation

Correct Answer is ["9.0"]

Explanation

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