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Questions 164

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Extract:

Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)


Question 1 of 5

A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?

Correct Answer: A

Rationale: Status asthmaticus with 80% pulse oximetry (
A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (
B) and nausea in pregnancy (
C) are less acute, as they do not indicate immediate life-threatening conditions.

Extract:


Question 2 of 5

A client with emphysema comes for a routine follow-up visit. The nurse assisting with the initial assessment knows that which manifestations are characteristic of emphysema? Select all that apply.

Correct Answer: A,C,D

Rationale: Emphysema causes air trapping, leading to barrel chest (
A), reduced exercise capacity (
C), and diminished breath sounds (
D). Crackles (
B) suggest fluid, and sputum (E) is more typical of chronic bronchitis.

Question 3 of 5

Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?

Correct Answer: C

Rationale: Persistent vomiting (
C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (
A), memory lapses (
B), and palpable shunt (
D) are not concerning.

Question 4 of 5

The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased

Correct Answer: A

Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (
A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (
B), anxiety (
C), or heart rate (
D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.

Question 5 of 5

Which of the following activities is most suitable for a 10-year old with asthma?

Correct Answer: B

Rationale: Swimming is ideal for children with asthma, as the humid environment reduces airway irritation, unlike high-exertion sports like soccer or basketball.

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