Nokea
Which clinical manifestation indicates to the nurse the child has cystic fibrosis?
- A. Wheezing with a productive cough.
- B. Excessive salty sweat secretions.
- C. Multiple vitamin deficiencies.
- D. Clubbing of all fingers.
Correct Answer: B
Rationale: Excessive salty sweat (B) is a hallmark of cystic fibrosis due to defective chloride transport, detectable via sweat chloride testing. Wheezing/cough (A) is non-specific. Vitamin deficiencies (C) and clubbing (D) occur later but are not diagnostic.
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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.
During suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal wall and creates a pulling sensation. What is the best action for the nurse to take?
- A. Release the suction by opening the vent
- B. Continue suctioning to remove the obstruction
- C. Increase the pressure
- D. Suction deeper
Correct Answer: A
Rationale: Releasing suction by opening the vent prevents trauma to the tracheal mucosa when the catheter adheres to the wall.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required?
- A. I should contact my health-care provider if my sputum changes color or amount.
- B. I will take my bronchodilator regularly to prevent having bronchospasms.
- C. This metered-dose inhaler gives a precise amount of medication with each dose.
- D. I need to return to the HCP to have my blood drawn with my annual physical.
Correct Answer: D
Rationale: Blood draws (D) are not routine for bronchitis, indicating misunderstanding. Sputum changes (A), bronchodilator use (B), and inhaler accuracy (C) reflect correct understanding.
Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?
- A. Airborne isolation.
- B. Droplet isolation.
- C. Reverse isolation.
- D. Strict isolation.
Correct Answer: A
Rationale: SARS is transmitted via respiratory droplets and possibly aerosols, requiring airborne isolation (A) with a negative pressure room and N95 masks. Droplet isolation (B) is insufficient for potential aerosol transmission. Reverse isolation (C) protects immunocompromised patients, not applicable here. Strict isolation (D) is not a standard term for SARS precautions.
When a previously negative client has a positive reaction to a tuberculin skin test, which information about follow-up is most correct?
- A. A skin test will be performed every 6 months.
- B. A routine chest X-ray is required every year.
- C. The client will need to live alone temporarily.
- D. Antituberculosis drugs will be prescribed.
Correct Answer: D
Rationale: A positive tuberculin test requires further evaluation (e.g., chest X-ray), and antituberculosis drugs may be prescribed for latent or active infection.