Nokea
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
- A. Crackles
- B. Rhonchi
- C. Stridor
- D. Wheezes
Correct Answer: D
Rationale: Wheezes are high-pitched musical sounds heard on expiration and indicate narrowed airways, commonly found in asthma patients.
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A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A nurse is reviewing the medical record of a client who has a fluid volume deficit. The nurse should expect which of the following findings?
- A. BUN 12 mg/dL
- B. Urine output 15 mL/hr
- C. Hct 43%
- D. Urine specific gravity 1.020
Correct Answer: B
Rationale: The correct answer is B: Urine output 15 mL/hr. In a client with fluid volume deficit, the body tries to conserve fluids by decreasing urine output. A urine output of 15 mL/hr indicates decreased renal perfusion and fluid conservation, which are common in fluid volume deficit. Choices A, C, and D are within normal ranges and do not specifically indicate fluid volume deficit. Choice A (BUN 12 mg/dL) is within the normal range and is not significantly altered in fluid volume deficit. Choice C (Hct 43%) is also within normal range and may be elevated in dehydration, but not specific to fluid volume deficit. Choice D (Urine specific gravity 1.020) is concentrated, but not definitive for fluid volume deficit.
A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
A nurse is caring for a client who is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.
- A. Aromatherapy
- B. Biofeedback
- C. Guided imagery
- D. Yoga
Correct Answer: A
Rationale: Aromatherapy uses essential oils from plants to promote relaxation, improve mood, and support immune function.
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
- A. Erythema
- B. Pallor
- C. Coolness
- D. Drainage
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice B) and coolness (choice C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.