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The nurse is completing the admission assessment on a 13-year-old client diagnosed with an acute exacerbation of asthma. Which signs and symptoms would the nurse expect to find?
- A. Fever and crepitus.
- B. Rales and hives.
- C. Dyspnea and wheezing.
- D. Normal chest shape and eupnea.
Correct Answer: C
Rationale: Asthma exacerbation causes dyspnea and wheezing (C) from bronchoconstriction. Fever/crepitus (A), rales/hives (B), and normal breathing (D) are unrelated or incorrect.
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The client experiencing a severe allergic reaction becomes pulseless. The nurse shakes the client, shouts the client's name, and activates the emergency medical response system. Which nursing action becomes the next priority?
- A. Administer a single blow to the sternum.
- B. Give two quick breaths that make the chest visibly rise.
- C. Begin chest compressions at a rate of 100 per minute.
- D. Administer an epinephrine (Adrenalin) injection.
Correct Answer: C
Rationale: For a pulseless client, starting chest compressions immediately after activating the emergency response is the priority to restore circulation, per CPR guidelines.
The client diagnosed with exercise-induced asthma (EIA) is being discharged. Which information should the nurse include in the discharge teaching?
- A. Take two (2) puffs on the rescue inhaler and wait five (5) minutes before exercise.
- B. Warm-up exercises will increase the potential for developing the asthma attacks.
- C. Use the bronchodilator inhaler immediately prior to beginning to exercise.
- D. Increase dietary intake of food high in monosodium glutamate (MSG).
Correct Answer: A
Rationale: Two puffs of a rescue inhaler 5 minutes before exercise (A) prevents EIA. Warm-ups (B) reduce attacks, immediate use (C) is less effective, and MSG (D) is a trigger.
Because of the client's pleural effusion and advanced lung disease, what would the nurse expect to hear when assessing the breath sounds?
- A. Wheezing in the upper lobes
- B. A friction rub posterior to the affected area
- C. Crackles over the affected area
- D. Decreased sounds over the involved area
Correct Answer: D
Rationale: Pleural effusion causes decreased breath sounds over the affected area due to fluid accumulation compressing the lung.
A 48-year old homeless man, who is living in a local homeless shelter and is an IV drug user, has arrived to the clinic to have his PPD skin test assessed. What is considered a positive result?
- A. 5 mm induration
- B. 15 mm induration
- C. 9 mm induration
- D. 10 mm induration
Correct Answer: D
Rationale: 15 mm induration is positive in ALL people regardless of health history or risk factors. However, for patients who are homeless (living in homeless shelter) and are IV drug users, a 10 mm or more is considered positive.
Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.