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The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of 'impaired gas exchange.' Which is an expected outcome for this problem?
- A. Performs chest physiotherapy three (3) times a day.
- B. Able to complete activities of daily living.
- C. Ambulates in the hall several times during each shift.
- D. Alert and oriented to person, place, time, and events.
Correct Answer: D
Rationale: Alert/oriented status (D) indicates improved oxygenation from resolved gas exchange impairment. Physiotherapy (A) is an intervention, ADLs (B) and ambulation (C) are secondary outcomes.
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A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in so the results can be interpreted?
- A. 24-48 hours
- B. 12-24 hours
- C. 48-72 hours
- D. 24-72 hours
Correct Answer: C
Rationale: The PPD skin test (Mantoux) is read 48-72 hours after administration to assess for induration, as this is the standard timeframe for an accurate immune response to be visible.
You note your patient's sweat and urine is orange. You reassure the patient and educate him that which medication below is causing this finding?
- A. Ethambutol
- B. Streptomycin
- C. Isoniazid
- D. Rifampin
Correct Answer: D
Rationale: This medication will cause body fluids to turn orange.
The nurse knows that the correct way to position the hands when performing the abdominal thrust maneuver is with the thumb side of the closed fist on which part of the victim's abdomen?
- A. Directly on the manubrium
- B. Above the xiphoid process
- C. Below the navel
- D. Below the sternum
Correct Answer: B
Rationale: Positioning the fist above the xiphoid process (below the sternum) ensures safe and effective abdominal thrusts to dislodge the obstruction.
Select all the correct options that represent the pathophysiology of an asthma attack.
- A. The smooth muscle surrounding the alveoli constricts, limiting oxygenation.
- B. The mucosa lining experiences severe inflammation.
- C. The goblet cells within the mucosa lining produce excessive amounts of mucous.
- D. Too much carbon dioxide is exhaled due to hyperventilation and the patient experiences respiratory alkalosis.
Correct Answer: B,C
Rationale: Asthma involves inflammation of the airway mucosa and excessive mucus production by goblet cells. Smooth muscle constriction occurs in bronchioles, not alveoli, and hyperventilation typically leads to respiratory acidosis due to CO2 retention.
The client diagnosed with asthma is admitted to the emergency department with difficulty breathing and a blue color around the mouth. Which diagnostic test will be ordered to determine the status of the client?
- A. Complete blood count.
- B. Pulmonary function test.
- C. Allergy skin testing.
- D. Drug cortisol level.
Correct Answer: B
Rationale: Pulmonary function tests (B) assess airway obstruction in acute asthma. CBC (A), allergy testing (C), and cortisol levels (D) are not immediate diagnostic tools.