Nokea
The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.
You may also like to solve these questions
Divalproex sodium (Depakote) is prescribed for a 28-year-old female. Which lab test would the nurse expect prior to administration of the medication?
- A. Urine drug screen
- B. Pregnancy test
- C. CBC with differential
- D. Liver function tests
Correct Answer: B
Rationale: Divalproex is teratogenic; a pregnancy test is critical in females of childbearing age to prevent fetal harm.
A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct Answer: D
Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.
The LPN/LVN is to assist the school nurse in scoliosis screening. What instructions should be given to the students?
- A. Wear a bathing suit under your clothes on the examination day.
- B. Bring a urine sample to school.
- C. Do not wash your hair the night before the exam.
- D. Wash your feet well the morning of the exam.
Correct Answer: A
Rationale: A bathing suit allows easy spinal visualization during scoliosis screening, ensuring modesty and efficiency.
The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
- A. Diarrhea
- B. Frequent burping
- C. Headache
- D. Sucking lip motions
Correct Answer: D
Rationale: Sucking lip motions suggest tardive dyskinesia, a contraindication for metoclopramide due to risk of worsening. Diarrhea , burping , and headache are not contraindications.
After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.