Nokea
Which of the following would indicate that a client with asthma is experiencing status asthmaticus?
- A. Wheezing on expiration only.
- B. Use of accessory muscles for breathing.
- C. Diminished breath sounds bilaterally.
- D. Productive cough with thick mucus.
Correct Answer: C
Rationale: Status asthmaticus, a life-threatening asthma exacerbation, is indicated by diminished breath sounds bilaterally due to severe airway obstruction. Wheezing, accessory muscle use, and productive cough are present in asthma but not specific to status asthmaticus.
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A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the:
- A. Pulse rate is normal.
- B. Pupils are reacting to light.
- C. Mucous membranes are pink.
- D. Systolic blood pressure is at least 80 mm Hg.
Correct Answer: D
Rationale: A systolic blood pressure of at least 80 mm Hg indicates effective CPR, as it reflects adequate circulation and perfusion.
The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.
Which of the following is the best way for the nurse to begin the preoperative interview?
- A. Walk in the client's room and ask, 'Are you Mrs. Smith?'
- B. Walk in the client's room, sit down, and take the client's blood pressure.
- C. Walk in the client's room, sit down, maintain eye contact, and introduce yourself.
- D. Walk in the client's room, and ask the client her name.
Correct Answer: C
Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
A client says, 'I hate the idea of being an invalid after they cut off my leg.' Which of the following would be the nurse's most therapeutic response?
- A. At least you will still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're lucky to have a wife to care for you.'
Correct Answer: B
Rationale: Encouraging the client to express feelings fosters coping and addresses emotional concerns.