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NEW QUESTION 42
Endotracheal tube cuff pressure should never exceed:

• A. 45 mm Hg
• B. 20 mm Hg
• C. 10 mm Hg
• D. 60 mm Hg

Answer: B

Explanation:
Explanation
(A) Pressure<10 mm Hg places the client at risk for aspiration. (B) Pressure in the endotracheal tube cuff should never exceed 20 mm Hg, because higher pressure places the client at risk for tracheal erosion. (C) A pressure of 45 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion. (D) A pressure of 60 mm Hg is an extremely high pressure in the endotracheal tube cuff. This places the client at great risk for tracheal erosion.

NEW QUESTION 43
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:

• A. Has no bowel sounds
• B. Has a urine output of 200 mL for 4 hours
• C. Develops a temperature of 102_F
• D. Cries easily and says she is having abdominal pain

Answer: C

Explanation:
Explanation/Reference:
Explanation:
(A) The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. (B) A temperature of 102_F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment.
(C) The client is expected to have no bowel soundsfor 24-48 hours after surgery because of the trauma to the bowel. (D) Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.

NEW QUESTION 44
A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

• A. Give moist O2at>40%
• B. Maintain on 100% O2
• C. Maintain O2at <40%
• D. Maintain O2at>40%

Answer: C

Explanation:
Explanation
(A) Retrolental fibroplasia is the result of prolonged exposure to high levels of O2in premature infants.
Complications are hemorrhage and retinal detachment. (B, C, D) O2concentration is too high.

NEW QUESTION 45
......

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