Nokea
Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
- A. Taking the client's temperature
- B. Assessing the client's blood pressure
- C. Monitoring the client's respiratory status
- D. Checking the client's pupillary response
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.
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You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gases below represent respiratory acidosis that is NOT compensated?
- A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
- B. pH 7.48, PaCO2 35, HCO3 22, PO2 85
- C. pH 7.20, PaCO2 20, HCO3 28, PO2 85
- D. pH 7.55, PaCO 63, HCO3 19, PO2 85
Correct Answer: A
Rationale: Respiratory acidosis is characterized by low pH (<7.35) and high PaCO2 (>45). Option A (pH 7.29, PaCO2 55, HCO3 23) shows uncompensated respiratory acidosis, as HCO3 is normal, indicating no renal compensation. Other options show normal pH, respiratory alkalosis, or invalid data.
Select all the following that can trigger an asthma attack:
- A. Sulfites
- B. Smoke
- C. Caffeine
- D. GERD
- E. Cold, windy weather
- F. Beta agonist
- G. Cockroaches
Correct Answer: A,B,D,E,G
Rationale: Triggers include sulfites, smoke, GERD, cold weather, and cockroaches. Caffeine and beta agonists are not typical triggers; beta agonists are treatments.
The client diagnosed with tuberculosis has been treated with antitubercular medications for six (6) weeks. Which data would indicate the medications have been effective?
- A. A decrease in the white blood cells in the sputum.
- B. The client's symptoms are improving.
- C. No change in the chest X-ray.
- D. The skin test is now negative.
Correct Answer: B
Rationale: Improved symptoms (B) after six weeks of TB treatment (e.g., reduced cough, fever) indicate medication efficacy. WBCs in sputum (A) are not a standard measure. Chest X-ray changes (C) lag behind clinical improvement. The skin test (D) remains positive post-exposure, regardless of treatment.
The clinic nurse is interviewing clients. Which information provided by a client warrants further investigation?
- A. The client uses Vicks VapoRub every night before bed.
- B. The client has had an appendectomy.
- C. The client takes a multiple vitamin pill every day.
- D. The client has been coughing up blood in the mornings.
Correct Answer: D
Rationale: Hemoptysis (D) suggests serious conditions (e.g., lung cancer, TB), requiring investigation. VapoRub (A), appendectomy (B), and vitamins (C) are benign.
A patient, who is receiving continuous IV Heparin for the treatment of a DVT, has an aPTT of 110 seconds. What is your next nursing action per protocol?
- A. Continue with the infusion because no change is needed based on this aPTT.
- B. Increase the drip rate per protocol because the aPTT is too low.
- C. Re-draw the aPTT STAT.
- D. Hold the infusion for 1 hour and decrease the rate per protocol because the aPTT is too high.
Correct Answer: D
Rationale: The aPTT is 110 seconds, which is too high. Any aPTT value greater than 80 seconds places the patient at risk for bleeding. Most Heparin protocols dictate that the nurse would hold the infusion for 1 hour and to decrease the rate of infusion. If the aPTT is less than 60 seconds, the dose would need to be increased and a bolus may be needed. aPTT values should be around 60-80 seconds to achieve a therapeutic response for Heparin.