Nursing Elites

1. A client in the emergency department is experiencing an acute asthma attack. Which assessment indicates an improvement in respiratory status?

• A. SaO2 95%
• B. Wheezing
• C. Retraction of sternal muscles
• D. Premature ventricular complexes (PVC's)

Correct answer: A

Rationale: An SaO2 of 95% indicates an improvement in the client's oxygen saturation, suggesting better respiratory status. In asthma exacerbation, a decrease in SaO2 levels would signal worsening respiratory distress. Wheezing, retraction of sternal muscles, and premature ventricular complexes are indicators of respiratory compromise and worsening respiratory status in acute asthma attacks. Monitoring SaO2 levels is crucial in assessing the effectiveness of interventions and guiding treatment decisions.

2. Which pulse's absence may not be a significant finding when a patient is admitted to the hospital?

• A. Apical
• B. Radial
• C. Pedal
• D. Femoral

Correct answer: C

Rationale: The absence of the pedal pulse may not be significant if the patient has poor peripheral circulation or if the healthcare provider is focused on other pulse points. The pedal pulse is often weaker and may not always be palpable due to various factors, making its absence less concerning in certain situations. However, the absence of other pulses like radial or femoral pulses may indicate more critical conditions and require immediate attention.

3. What is the initial technique used when examining a client's abdomen?

• A. Palpation
• B. Auscultation
• C. Percussion
• D. Inspection

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

4. A client with active tuberculosis is prescribed isoniazid, rifampin, pyrazinamide, and ethambutol. Which statement by the client indicates an understanding of the teaching?

• A. I can substitute one medication for another if I run out because they all fight infection.
• B. I will wash my hands each time I cough.
• C. I am glad I don't have to have any more sputum specimens.
• D. I don't need to worry about where I go once I start taking my medications.

Correct answer: B

Rationale: The correct statement indicating understanding of tuberculosis medication regimen is 'I will wash my hands each time I cough.' This statement shows knowledge of infection control practices to prevent the spread of tuberculosis. Washing hands after coughing helps in reducing the transmission of the disease to others. The other options are incorrect. Option A is incorrect as each medication in the regimen has a specific role, and substituting one for another can compromise the effectiveness of treatment. Option C is incorrect as obtaining sputum specimens is essential for monitoring treatment response. Option D is incorrect as the client should still adhere to infection control measures and avoid exposing others to tuberculosis.

5. What is the term for the body's ability to defend itself against specific invading agents such as bacteria, toxins, viruses, and foreign bodies?

• A. Hormones
• B. Secretion
• C. Immunity
• D. Glands

Correct answer: C

Rationale: The correct answer is C: Immunity. Immunity refers to the body's ability to protect itself against specific invading agents like bacteria, toxins, viruses, and foreign bodies by recognizing and destroying them. It is a crucial defense mechanism that helps maintain health and prevent infections and diseases. Choices A, B, and D are incorrect because hormones are chemical messengers, secretion is the process of releasing substances, and glands are organs that produce and release substances, none of which specifically relate to the body's defense against invading agents.

Similar Questions