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Questions 148

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Question 1 of 5

An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:

Correct Answer: A

Rationale: Acute laryngotracheobronchitis (croup) is characterized by inspiratory stridor and a harsh, barking cough due to upper airway inflammation and narrowing.

Question 2 of 5

The chest tube drainage system has continuous bubbling in the water seal chamber. When the nurse clamps different areas of the tube to find out where the bubbling stops, he is checking for:

Correct Answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak, either from the lung or the system. Clamping helps locate the source of the leak.

Question 3 of 5

Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.

Correct Answer: B,C,E

Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (
B), measuring urinary output (
C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (
A) and monitoring a transfusion (
D) require a nurse's assessment skills.

Question 4 of 5

The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply.

Correct Answer: B, C, D

Rationale: Viral hepatitis causes increased AST, elevated ammonia, and low serum albumin due to liver damage. ALT is typically increased, not decreased, and prothrombin time is prolonged.

Question 5 of 5

An elderly female is admitted with a fractured right femoral neck. Which clinical manifestation would the nurse expect to find?

Correct Answer: D

Rationale: A femoral neck fracture typically causes shortening of the affected leg due to muscle contraction pulling the bone fragments together, along with external rotation and limited movement.

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