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vsim Kenneth Bronson pre_post
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vsim Kenneth Bronson pre/postThe nurse is auscultating lung sounds. What lung sound is associated with
narrowing of the airway?
Wheezing
Rational: Wheezing is a high-pitched, musical sound associated with airway
narrowing. Crackles are described as a popping sound heard during inspiration
from fluid or delayed opening of collapsed alveoli. Bronchophony or egophony
can be auscultated when there is increased lung density from pneumonia and
pulmonary edema.
Epinephrine is the first-line drug for anaphylaxis because of which of the
following properties?
Relaxes bronchial muscle
Rationale:Epinephrine relaxes bronchial smooth muscle by stimulating beta2
receptors; this improves oxygenation, decreasing respiratory distress.
Epinephrine does not decrease inflammation. Epinephrine increases blood
pressure. Although Epinephrine may decrease urticaria, that is not the primary
reason it is given during anaphylaxis.
What is the priority action by the nurse when a client experiences sudden
respiratory distress?
Assess the airway
Rationale:The priority action is to assess the airway. Raising the head of bed will
improve lung expansion. The provider should be notified and IV line may be
needed, but assessing the client is the priority.
, Which of the following represent initial signs and symptoms of a client in
respiratory distress? (Select all that apply.)
Hypoxemia , Dyspnea , Tachypnea
Rationale:Dyspnea and tachypnea accompanied by low oxygen in the blood are
associated with respiratory distress. Cyanosis is a very late indicator of hypoxia
to the tissues. Fever is an indication of infection.
The client experiencing an anaphylactic reaction may experience which of the
following signs and symptoms? (Select all that apply.)
Dyspnea , Bronchospasm , Pruritus , Laryngeal edema
Rationale:Mild systemic reactions consist of peripheral tingling, warmth, a
sensation of fullness in the mouth and throat, nasal congestion, periorbital
swelling, pruritus, sneezing, and tearing of the eyes. Moderate systemic
reactions may include flushing and anxiety in addition to any of the milder
symptoms. More serious reactions include bronchospasm, laryngeal edema,
severe dyspnea, cyanosis, and hypotension. Dysphagia (difficulty swallowing),
abdominal cramping, vomiting, diarrhea, and seizures can also occur. Cardiac
arrest and coma may follow.
When a client presents to the emergency department with pneumonia, which
signs and symptoms would the nurse expect the client to exhibit? (Select all that
apply.)
Dyspnea , Fatigue , Orthopnea , Fever
Rationale:Fever is present with the infection. Clients will exhibit dyspnea,
preferring to be propped up or sitting up due to orthopnea (shortness of breath
when reclining or supine). The client is fatigued from the work of breathing.
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