Nokea
Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?
- A. Distant breath sounds
- B. Increased heart sounds
- C. Decreased anteroposterior chest diameter
- D. Collapsed neck veins
Correct Answer: A
Rationale: Distant breath sounds are characteristic of emphysema due to increased anteroposterior chest diameter, overdistention, and air trapping.
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An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
- A. Alpha-fetoprotein
- B. Estriol level
- C. Indirect Coombs
- D. Lecithin sphingomyelin ratio
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio measures fetal lung maturity by assessing surfactant production, critical for preventing respiratory distress syndrome in preterm infants.
A client suspects that she is pregnant. She reports two missed menstrual periods. The first day of her last menstrual period was August 3. Her estimated date of confinement would be:
- A. 7-Nov
- B. 10-Nov
- C. 7-May
- D. 10-May
Correct Answer: D
Rationale: Using Nägele's rule (LMP - 3 months + 7 days + 1 year), August 3 leads to an estimated delivery date of May 10.
Which finding is considered a risk factor in the development of leukemia?
- A. The client is an avid stamp collector.
- B. The client works as a computer programmer.
- C. The client had radiation for Hodgkin's lymphoma.
- D. The client's grandmother had stomach cancer.
Correct Answer: C
Rationale: Radiation exposure such as from treatment for Hodgkin’s lymphoma is a known risk factor for leukemia. Stamp collecting computer programming and a family history of stomach cancer are not established risk factors.
Which client should be assigned to the nursing assistant?
- A. The 18-year-old with a fracture to two cervical vertebrae
- B. The infant with meningitis with a temperature of 101°F
- C. The elderly client with a thyroidectomy four days ago
- D. The client with a thoracotomy two days ago
Correct Answer: C
Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).
The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?
- A. The client is able to talk.
- B. The client is alert and oriented.
- C. The client's O2 saturation is 97%.
- D. The client's chest movements are uninhibited.
Correct Answer: C
Rationale: An O2 saturation of 97% directly indicates adequate oxygenation from respiratory efforts. Talking (A), alertness (B), and chest movement (D) are indirect and less specific.