Correct Answer: D

Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.

Correct Answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

Correct Answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

Correct Answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

Correct Answer: D

Rationale: During the removal of a chest tube, instructing the client to perform the Valsalva maneuver is essential. This maneuver involves holding the breath and bearing down, which helps prevent air from entering the pleural space during tube removal, reducing the risk of pneumothorax. Instructing the client to lie on their left side, use the incentive spirometer, or cough at regular intervals is not appropriate during the chest tube removal process.