Nokea
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
- A. Diffuse expiratory wheezing
- B. Loose, productive cough
- C. No relief from inhalant
- D. Fever and chills
Correct Answer: A
Rationale: In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.
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After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
All of the following clients assigned to LPN/LVN ring their call bells. Which client needs the most immediate attention?
- A. A 72-year-old diabetic who is blind says she has to go to the bathroom.
- B. A 75-year-old client who has rheumatoid arthritis asks for pain medication.
- C. A client who has a blood transfusion running says her chest hurts.
- D. A postoperative client says he is in pain and wants a pain shot.
Correct Answer: C
Rationale: Chest pain during a blood transfusion suggests a possible transfusion reaction, a life-threatening emergency requiring immediate intervention. Bathroom needs, arthritis pain, or postoperative pain are less urgent.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
The nurse administers the prescribed dose of hydromorphone 2 mg to a client who had knee replacement surgery 2 days ago. Which assessment finding is most concerning to the nurse?
- A. Client falls asleep while talking to the nurse
- B. Client has had no bowel movement for 2 days
- C. Client has one episode of nonbilious emesis
- D. Client reports experiencing pruritus
Correct Answer: A
Rationale: Falling asleep mid-conversation (A) may indicate opioid-induced respiratory depression, a life-threatening concern. Constipation (B), emesis (C), and pruritus (D) are less urgent side effects.