Nokea
The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.
- A. Accessory muscle use
- B. Chest tightness
- C. High-pitched expiratory wheeze
- D. Prolonged inspiratory phase
- E. Tachypnea
Correct Answer: A,B,C,E
Rationale: Severe asthma exacerbations cause accessory muscle use, chest tightness, high-pitched wheezing, and tachypnea due to airway obstruction. Prolonged expiration, not inspiration, is typical as air is trapped.
You may also like to solve these questions
The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.
The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?
- A. UAP applies the anti-embolism stockings while maintaining the client in supine position
- B. UAP carefully smoothes out any wrinkles over the length of the stockings
- C. UAP checks that the toe opening of the stockings is located on the plantar side of the foot
- D. UAP rolls down and folds over the excess material at the top of the stockings
Correct Answer: D
Rationale: Rolling and folding the stockings creates pressure points, risking skin breakdown and poor circulation. Supine application and correct toe opening placement are appropriate.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.
A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?
- A. 800
- B. 1080
- C. 1440
- D. 1960
Correct Answer: C
Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.