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The nurse is assessing a client with a history of asthma who presents with decreased breath sounds and prolonged expiration. The nurse should prioritize which of the following actions?
- A. Administer a bronchodilator as ordered.
- B. Encourage the client to cough and deep breathe.
- C. Obtain a chest X-ray.
- D. Position the client supine.
Correct Answer: A
Rationale: Decreased breath sounds and prolonged expiration indicate an asthma exacerbation with bronchoconstriction, requiring a bronchodilator to open airways. Coughing (B) is ineffective during an attack, X-rays (C) are diagnostic, and supine positioning (D) worsens breathing.
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The nurse is caring for a client with a history of chronic kidney disease who is receiving hemodialysis. Which of the following findings would require immediate intervention?
- A. Blood pressure of 140/90 mmHg.
- B. Weight gain of 1 kg since last dialysis.
- C. Bright red blood in the dialysis tubing.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: C
Rationale: Bright red blood in the dialysis tubing indicates a potential access site bleed or tubing disconnection, requiring immediate intervention to prevent blood loss. Mild hypertension (A) and weight gain (B) are common, and a normal potassium level (D) is unremarkable.
The nurse on the floor will perform peripheral IV site insertion.
Her performance is based on:
- A. Hospital policies and procedures.
- B. Nursing Standards of Practice.
- C. Doctor's orders.
- D. IV regulation developed by the Board of Nursing
Correct Answer: B
Rationale: Nursing Standards of Practice guide safe and competent IV insertion.
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: The belief that every person is worthy of dignity and respect is foundational to psychiatric mental health nursing, emphasizing client-centered care. The other options are also relevant but not the primary belief highlighted here. Psychosocial Integrity
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.