Nokea
The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?
- A. Bilateral wheezing.
- B. Decreased breath sounds on one side.
- C. Clear, resonant percussion sounds.
- D. Slow, shallow respirations.
Correct Answer: B
Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse
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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.
Which assessment finding in a client with COPD indicates to the nurse that the respiratory problem is chronic?
- A. Wheezing on exhalation
- B. Productive cough
- C. Clubbing of fingers
- D. Cyanosis
Correct Answer: C
Rationale: Clubbing of fingers is a sign of chronic hypoxia, indicative of long-standing COPD, unlike wheezing or cough, which can occur in acute or chronic stages.
The nurse is caring for a 28-year-old female with a long history of heroin addiction. The client tells the nurse that she started off using a small amount recreationally, but as time went on, she needed more and more heroin to feel a high. The nurse recognizes this as
- A. addiction.
- B. dependence.
- C. tolerance.
- D. withdrawal.
Correct Answer: C
Rationale: Tolerance is the need for increasing doses to achieve the same effect, as described in the client’s heroin use.
The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.
A client is admitted with a possible bowel obstruction. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
- A. Tell me about your pain.'
- B. What does your vomit look like?'
- C. Describe your usual diet.'
- D. Have you noticed an increase in abdominal size?'
Correct Answer: C
Rationale: Diet history is less directly related to diagnosing a bowel obstruction compared to pain, vomiting characteristics, or abdominal distension, which are hallmark symptoms.