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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.
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A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.
A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
- A. Have the client remove the existing dressing while the nurse prepares sterile supplies
- B. Wear clean gloves for removal and application of a new dressing
- C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
- D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing
Correct Answer: C
Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.
A patient has been ordered to get Tegretol for the first time. Which of the following side effects is not associated with Tegretol?
- A. Sore throat
- B. Vertigo
- C. Fever
- D. Shortness of breath
Correct Answer: D
Rationale: A-C are associated side effects of Tegretol.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).
The nurse is assessing for jaundice in a client who has dark skin. What is the best way to do this?
- A. Ask the client if his/her stool has changed color
- B. Look at the client's sclera
- C. Pinch the nail beds and observe the color
- D. Look at the client's fingers
Correct Answer: B
Rationale: The sclera (white of the eyes) reliably shows yellowing in jaundice, even in dark skin, unlike stool color, nail beds, or fingers, which are less specific.