Section: Questions Set D
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.

(A) According to Nagele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 -3 mo = September 17). (B, C, D) These answers are incorrect.

Explanation/Reference:
Explanation:
(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.

Explanation/Reference:
Explanation:
(A) The teenager is already coping ineffectively and requires early detection and treatment, which is secondary prevention. (B) The client must be sent to a rehabilitation unit, which requires tertiary prevention. (C) Reducing the incidence of disease through education supports primary prevention. (D) A client with identified symptoms of post-traumatic stress disorder requires intervention by treatment.

Explanation
(A) This action would further increase the client's blood sugar. (B) NPH insulin is an intermediate-acting insulin, with an average of 4-6 hours before onset of action. The client needs insulin that will act immediately.
During a ketoacidotic state, the client is dehydrated, so any insulin administered SC will be poorly absorbed.
(C) Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies. (D) This action would further increase the client's blood sugar.