Nokea
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
- A. Inspiratory stridor and harsh cough
- B. Strident cough and drooling
- C. Wheezing and intercostal retractions
- D. Expiratory wheezing and nonproductive cough
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) is characterized by inspiratory stridor and a harsh, barking cough due to upper airway inflammation and narrowing.
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The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
The nurse is caring for a client with an endemic goiter. The nurse recognizes that the client's condition is related to:
- A. Living in an area where the soil is depleted of iodine
- B. Eating foods that decrease the thyroxine level
- C. Using aluminum cookware to prepare the family's meals
- D. Taking medications that decrease the thyroxine level
Correct Answer: A
Rationale: Endemic goiter is caused by iodine deficiency, often due to low iodine levels in soil, leading to inadequate thyroid hormone production.
The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?
- A. give the next dose as ordered
- B. wait 2 hours and redraw the trough
- C. wait 30 minutes and redraw the trough
- D. hold the dose and notify the health care provider
Correct Answer: A
Rationale: A vancomycin trough of 14 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the next dose can be given as ordered.
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- A. Hib titer
- B. Mumps vaccine
- C. Hepatitis B vaccine
- D. MMR
Correct Answer: C
Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.
According to the American Heart Association (2005) guidelines the compression-to-ventilation ratio for one rescuer cardiopulmonary resuscitation is:
- A. 10:01
- B. 20:02
- C. 30:02:00
- D. 40:01:00
Correct Answer: C
Rationale: The 2005 AHA guidelines specify a 30:2 compression-to-ventilation ratio for one-rescuer CPR in adults.