Nokea
The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective?
- A. Episodes of spasmodic coughing have decreased
- B. No wheezes are audible on chest auscultation
- C. Oxygen saturation has increased from 88% to 93%
- D. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min
Correct Answer: B
Rationale: Absence of wheezes indicates open airways, the primary goal of asthma treatment. Reduced coughing and improved oxygen saturation are positive but less specific than clear lungs.
You may also like to solve these questions
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: This client is receiving secondary prevention. The current focus of health care is on preventive care. Leavell and Clark (1965) described the three levels of preventive care as primary, secondary, and tertiary. Secondary preventive care focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems.
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action?
- A. Administers the medication in small amounts at the back of the cheek using a syringe
- B. Allows the client to sip the medication from a cup
- C. Expels the medication from a dropper onto the back of the tongue
- D. Mixes the medication in the infant’s bottle of formula
Correct Answer: A
Rationale: Administering small amounts at the back of the cheek with a syringe ensures safe delivery and reduces choking risk in a 2-month-old. Cups, tongue administration, and mixing with formula are unsafe or ineffective.
The client is admitted to the labor and delivery unit with preeclampsia. An IV of magnesium sulfate is begun per pump. Which finding would indicate hypermagnesemia?
- A. Urinary output of $60 \mathrm{ml}$ per hour
- B. Respirations of 30 per minute
- C. Absence of the knee-jerk reflex
- D. Blood pressure of $150 / 80$
Correct Answer: C
Rationale: Hypermagnesemia, a risk of magnesium sulfate therapy, causes symptoms like loss of deep tendon reflexes (e.g., knee-jerk reflex), respiratory depression, and hypotension. Urinary output of 60 ml/hour is normal, respirations of 30 suggest tachypnea, and BP of 150/80 is not specific to hypermagnesemia.