Question

The nurse would check for leaks in the chest tube and water seal system when:

Answer 1

Correct Answers:

There is continuous bubbling in the water-seal chamber.

Rationale :

🔸Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system. 🔸The water-seal chamber is designed to act as a one-way valve, allowing air to exit the pleural space without letting air in. 🔸Intermittent bubbling may be expected during exhalation or coughing, but constant bubbling suggests a leak. 🔸 The nurse should investigate the tubing, connections, and drainage system to identify the source of the air leak.

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Answer 2

Correct Answers:

Blood pressure of 90/50

Rationale :

🔥Nitroglycerin is a potent vasodilator that can cause hypotension. 🔥A BP of 90/50 mmHg is a critical value that may worsen with nitroglycerin infusion, leading to reduced coronary perfusion and possible shock. 🔥This finding must be reported immediately before administering the medication. 🔥 Heart rate and ECG changes should be monitored, but hypotension presents the greatest immediate danger in this context.

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Answer 3

Correct Answers:

Change position slowly to prevent orthostatic hypotension

Rationale :

🔥Carbidopa/levodopa, used to treat Parkinson’s disease, frequently causes orthostatic hypotension, especially early in therapy. 🔥Clients must be taught to rise slowly from sitting or lying positions to prevent falls or dizziness. 🔥 It is not a drug without side effects, and skipping or doubling doses is unsafe. 🔥 Adherence to scheduled dosing and awareness of adverse effects is essential for safety and effectiveness.

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Answer 4

Correct Answers:

Relief of chest pain

Rationale :

🔹IV nitroglycerin is administered in the setting of acute myocardial infarction (AMI) to relieve myocardial ischemia, which presents as chest pain. 🔹 Its effectiveness is measured by pain relief, not changes in heart rate, dysrhythmia frequency, or BP reduction. 🔹 Pain relief indicates improved coronary perfusion and reduced myocardial oxygen demand.

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Answer 5

Correct Answers:

Ventricular dysrhythmias

Rationale :

🔹The anterior-lateral wall of the heart is supplied by the left anterior descending artery, and infarction in this area often affects the left ventricle. 🔹Increasing the risk for ventricular dysrhythmias, which are the most common cause of sudden cardiac death post-MI. 🔹Continuous cardiac monitoring is essential in the first hours following an MI to detect life-threatening arrhythmias early.

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Answer 6

Correct Answers:

Uncompensated metabolic acidosis.

Rationale :

🔹ABG interpretation: pH = 7.32 (low) HCO₃ = 16 mEq/L (low) PaCO₂ = 33 mmHg (low) 🔹The primary abnormality is low HCO₃, indicating metabolic acidosis. 🔹The respiratory system is attempting partial compensation by lowering CO₂, but the pH remains abnormal, so this is uncompensated. 🔹The condition might arise from renal failure, diarrhea, or lactic acidosis.

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Answer 7

Correct Answers:

56

Rationale :

🔸Formula: (Volume × Drop factor) ÷ Time = drops/min (500 mL × 10 gtt/mL) ÷ 90 min = 5000 ÷ 90 = 55.5 ≈ 56 gtt/min 🔸This rate ensures proper fluid administration over the prescribed time. Accuracy is vital in preventing fluid overload or underhydration.

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Answer 8

Correct Answers:

take pyridostigmine 30-60 minutes before meals to improve muscle function."

Rationale :

🔸Pyridostigmine is an anticholinesterase used in myasthenia gravis to improve neuromuscular transmission. 🔸 Taking it 30–60 minutes before meals improves swallowing and chewing ability, helping reduce the risk of aspiration. 🔸 It should not be crushed if sustained-release and should be taken as prescribed, not as needed.

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Answer 9

Correct Answers:

Tachypnea

Rationale :

🔸Acute respiratory distress syndrome (ARDS) is characterized by refractory hypoxemia and non-cardiogenic pulmonary edema. 🔸 The earliest and most common sign is tachypnea, or rapid breathing, as the body attempts to compensate for low oxygen levels. 🔸Wheezing is not typical; instead, crackles may be heard later. 🔸 Bradycardia and hypertension are not hallmark features in early ARDS.

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Answer 10

Correct Answers:

Muscle rigidity and bradykinesia

Rationale :

🔹Parkinson’s disease is a progressive neurodegenerative disorder marked by muscle rigidity, bradykinesia (slowness of movement), and resting tremors. 🔹These symptoms result from the loss of dopamine-producing neurons in the substantia nigra. 🔹 The other options are unrelated to Parkinson’s disease.

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RN Medsurg nurs 300 Exam 4

No.

1 : The nurse would check for leaks in the chest tube and water seal system when:

2 : The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

3 : A nurse is providing teaching to a client newly diagnosed with Parkinson's disease who is prescribed carbidopa/levodopa. What should be included in client teaching?

4 : The nurse administers IV nitroglycerin to a client diagnosed with an acute myocardial infarction. In evaluating the effectiveness of this intervention, the nurse should monitor for:

5 : The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:

6 : The nurse is caring for a client with the following arterial blood gas (ABG) results: pH 7.32, PaCO₂ 33 mmHg, PaO₂ 88 mmHg, and HCO₃ 16 mEq/L. The nurse would interpret these results as:

7 : A patient is prescribed 500 ml of normal saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt./mL. At what rate should the nurse regulate the IV (gWmin)? (Round to the nearest whole number.)

8 : The nurse is providing education for a client diagnosed with myasthenia gravis (MG) taking pyridostigmine. The nurse understands teaching has been effective when the client states, "l will

9 : The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

10 : The nurse assessing the client diagnosed with Parkinson's disease (PD) would expect which of the following assessment findings?

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