Nokea
The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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What is the technique called that manages tremors caused by Parkinson's disease?
- A. Deep brain stimulation
- B. Transcranial magnetic stimulation
- C. Vagus nerve stimulation
- D. Electroconvulsive therapy
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
- A. Loud wheezing
- B. Increased respiratory rate
- C. Use of accessory muscles
- D. Silent chest
Correct Answer: D
Rationale: The correct answer is D: Silent chest. This finding indicates severe airway obstruction and impending respiratory failure, requiring immediate intervention to prevent respiratory arrest. Silent chest means minimal or absent breath sounds, suggesting no air movement, which is a critical emergency situation. Wheezing (A), increased respiratory rate (B), and use of accessory muscles (C) are common in asthma attacks but do not indicate as severe a condition as a silent chest. Monitoring and addressing a silent chest promptly is crucial in managing acute asthma exacerbations.
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
A client is experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?
- A. Albuterol (Proventil)
- B. Ipratropium (Atrovent)
- C. Salmeterol (Serevent)
- D. Fluticasone (Flovent)
Correct Answer: A
Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms.
Summary of other choices:
B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief.
C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations.
D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations
What information should you immediately report to the physician?
- A. The parent is unsure about the child's tetanus immunization status
- B. The child is upset and pulls out the IV
- C. The parent declines the IV conscious sedation
- D. The parent wants information about the IV conscious sedation
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.