The nurse recognizes that the primary physiologic problem affecting clients with emphysema is:

Increase in cellular size of the bronchi and bronchioles.

Overexpansion of the diaphragm.

A decreased ability to inhale.

Destruction of alveolar walls and loss of lung elasticity.

Answer and Explanation

The Correct Answer is D

Choice A reason:

An increase in cellular size of the bronchi and bronchioles is not the primary issue in emphysema. Emphysema primarily affects the alveoli, the tiny air sacs in the lungs, rather than the bronchi and bronchioles.

Choice B reason:

Overexpansion of the diaphragm is not a primary problem in emphysema. While the diaphragm may become flattened due to hyperinflation of the lungs, this is a secondary effect rather than the primary issue.

Choice C reason:

A decreased ability to inhale is not the main problem in emphysema. The primary issue is difficulty exhaling due to the loss of elasticity in the alveolar walls, which leads to air trapping and hyperinflation

Choice D reason:

Destruction of alveolar walls and loss of lung elasticity is the primary physiologic problem in emphysema. This destruction leads to reduced surface area for gas exchange and impaired lung function. The loss of elasticity makes it difficult for the lungs to expel air, leading to air trapping and hyperinflation.

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Free Nursing Study Resources

Correct Answer is ["25"]

Explanation

The nurse should regulate the IV flow at 25 gtts/min.

Calculation and Answer

Step 1: Determine the total volume to be infused.

Volume = 100 mL

Step 2: Determine the time over which the infusion will occur.

Time = 1 hour = 60 minutes

Step 3: Determine the drip factor.

Drip factor = 15 gtts/mL

Step 4: Calculate the IV flow rate using the formula:

Flow rate (gtts/min) = (Volume (mL) × Drop factor (gtts/mL)) ÷ Time (min)

Step 5: Substitute the values into the formula.

Flow rate (gtts/min) = (100 mL × 15 gtts/mL) ÷ 60 min

Step 6: Perform the multiplication.

100 mL × 15 gtts/mL = 1500 gtts

Step 7: Perform the division.

1500 gtts ÷ 60 min = 25 gtts/min

The nurse should regulate the IV flow at 25 gtts/min.

A. Listening to at least one full respiration in each location. B. Instructing the client to breathe in and out rapidly while listening to breath sounds. C. Listening to breath sounds through the hospital gown or clothing. D. Instructing the client to take slow deep breaths through his or her nose. E. Listening as the client inhales, then goes to the next site during exhalation.

Correct Answer is ["B","C"]

Explanation

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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The nurse recognizes that the primary physiologic problem affecting clients with emphysema is:

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Naxlex Comprehensive Predictor Exams

The nurse receives an order to administer drug R 300 mg IVPB over one hour. Drug R is available as 300 mg in 100 mL NSS. The drip factor of the piggyback tubing is 15 gtts/mL. At what rate should the nurse regulate the IV flow?

Correct Answer is ["25"]

Explanation

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)

Correct Answer is ["B","C"]

Explanation

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