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What information does the nurse need to know first before recommending further action?
- A. What is the victim's age?
- B. Can the victim cough?
- C. How is the victim positioned?
- D. Can the victim still swallow?
Correct Answer: B
Rationale: Determining if the victim can cough assesses whether the airway is partially or completely obstructed, guiding the next steps.
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Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.
The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax?
- A. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures.
- B. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere.
- C. The injury allows air into the pleural space but prevents it from escaping from the pleural space.
- D. A tension pneumothorax results from a puncture of the pleura during a central line placement.
Correct Answer: C
Rationale: Tension pneumothorax traps air in the pleural space (C), increasing pressure. Bleb rupture (A) causes simple pneumothorax, free air movement (B) is open pneumothorax, and central line (D) is a cause, not definition.
The nurse is caring for a woman who is admitted with pneumonia. On admission, the client is anxious and short of breath but able to respond to questions. One hour later, the client becomes more dyspneic and less responsive, answering only yes and no questions. What is the best action for the nurse to take at this time?
- A. Stimulate the client until the client responds.
- B. Increase the oxygen from the ordered 6 L to 10 L.
- C. Assess the client again in 15 minutes.
- D. Notify the charge nurse of the change in the client's mental status.
Correct Answer: D
Rationale: A change in mental status with worsening dyspnea indicates potential deterioration, requiring immediate notification of the charge nurse.
To prevent the client with a head cold from developing a secondary ear infection, which recommendation is most appropriate?
- A. Sleeping with the head elevated
- B. Blaving the nose very gently
- C. Inserting cotton into the ears
- D. Massaging the area behind the ears
Correct Answer: B
Rationale: Blowing the nose gently prevents excessive pressure in the Eustachian tubes, which can lead to fluid buildup and secondary ear infections.
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.