Nokea
The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.
- A. Accessory muscle use
- B. Chest tightness
- C. High-pitched expiratory wheeze
- D. Prolonged inspiratory phase
- E. Tachypnea
Correct Answer: A,B,C,E
Rationale: Severe asthma exacerbations cause accessory muscle use, chest tightness, high-pitched wheezing, and tachypnea due to airway obstruction. Prolonged expiration, not inspiration, is typical as air is trapped.
You may also like to solve these questions
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
Which incidence should be documented on an unusual incident report?
- A. The client leaves the hospital against the doctor's advice.
- B. The client develops a fever after receiving a blood transfusion.
- C. The client reports an upset stomach after taking an antibiotic.
- D. The client falls in her bathroom.
Correct Answer: D
Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.
A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
- A. Norplant is safe and may be removed easily
- B. Oral contraceptives should not be used by smokers
- C. Depo-Provera is convenient with few side effects
- D. The IUD gives protection from pregnancy and infection
Correct Answer: B
Rationale: Oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.
A father brings his 17-year-old son to a walk-in clinic. The client reports a sudden severe headache. He has a temperature of 104°F and a purple rash. What is the best action for the nurse at this time?
- A. Prepare for a throat culture
- B. Schedule him for an appointment later in the day
- C. Isolate and alert the physician immediately
- D. Obtain a urine specimen
Correct Answer: C
Rationale: Symptoms suggest meningococcal meningitis, a medical emergency requiring isolation and immediate physician notification.