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Questions 148

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Extract:


Question 1 of 5

The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?

Correct Answer: C

Rationale: An O2 sat of 78% indicates severe hypoxemia, so applying oxygen is the first action to stabilize the child.

Question 2 of 5

The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?

Correct Answer: D

Rationale: implementation, fixed and dilated pupil represents a neurological emergency

Question 3 of 5

Which of the following postpartal clients is at greatest risk for hemorrhage?

Correct Answer: D

Rationale: A gravida 4 para 3 with a Caesarean section is at higher risk for hemorrhage due to uterine atony from multiple pregnancies and surgical delivery.

Question 4 of 5

The nurse is assessing a client with a closed reduction of a fractured femur. Which finding should the nurse report to the physician?

Correct Answer: A

Rationale: Chest pain and shortness of breath may indicate a pulmonary embolism, a serious complication requiring immediate reporting.

Question 5 of 5

The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:

Correct Answer: A

Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.

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