A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to document the findings (Option A). The rationale behind this is that bronchial breath sounds, which are described as harsh and hollow, are normal over the trachea and larynx. By documenting this assessment finding, the nurse is accurately recording the normal physiological sounds heard in this area, which is crucial for providing a complete and accurate patient assessment. Option B, administering oxygen therapy, is incorrect in this situation because the presence of bronchial breath sounds over the trachea and larynx does not indicate a need for oxygen therapy. This option is not relevant to the assessment findings provided in the question. Option C, positioning the client in high-Fowler position, is also incorrect as it does not address the specific assessment findings of bronchial breath sounds over the trachea and larynx. Positioning the client in high-Fowler position is more commonly associated with improving oxygenation in patients with respiratory distress or for facilitating breathing, which is not indicated based on the assessment findings in this question. Option D, administering prescribed albuterol, is also incorrect as bronchial breath sounds over the trachea and larynx do not suggest the need for albuterol administration. Albuterol is typically used to treat conditions such as asthma or chronic obstructive pulmonary disease (COPD) characterized by wheezing rather than the normal bronchial sounds heard over the trachea and larynx. Educationally, understanding normal and abnormal breath sounds is essential for nurses to accurately assess and monitor patients' respiratory status. By differentiating between normal and abnormal findings, nurses can provide appropriate interventions and escalate care as needed. Documenting findings is a fundamental aspect of nursing practice as it ensures accurate communication among healthcare providers and contributes to the overall quality of patient care.

Correct Answer: B

Rationale: The correct answer is B) Losing weight before you get pregnant will help prevent gestational hypertension. This is because obesity is a well-known risk factor for developing hypertension during pregnancy. By losing weight before conception, the woman can reduce this risk factor and promote a healthier pregnancy. Option A is incorrect because there are indeed ways to reduce the risk factors for gestational hypertension, and weight management is a key strategy. Option C is incorrect because while maintaining a healthy diet is important during pregnancy, there is not enough evidence to suggest that specifically consuming high protein and iron will prevent gestational hypertension. Option D is incorrect because although advanced maternal age is a risk factor for gestational hypertension, it is not something the woman can actively modify or change to reduce her risk. In an educational context, it is crucial for nurses to provide evidence-based information to women about how they can reduce their risks for complications during pregnancy. By understanding modifiable risk factors like weight, women can take proactive steps to promote a healthy pregnancy and reduce the chances of developing gestational hypertension. This empowers women to make informed decisions about their health and well-being before and during pregnancy.

Correct Answer: A

Rationale: In the context of a client with acute respiratory distress syndrome (ARDS), the correct clinical manifestation to expect is dyspnea (A). Dyspnea is a common symptom of ARDS as it indicates difficulty in breathing, which is a hallmark feature of this condition. ARDS leads to severe oxygenation problems in the body, resulting in dyspnea as the body struggles to compensate for the lack of oxygen. Option B, bradycardia, is incorrect as clients with ARDS often experience tachycardia rather than bradycardia. Tachycardia is the body's compensatory mechanism to increase cardiac output and oxygen delivery to tissues in response to hypoxia, which is commonly seen in ARDS. Option C, electrolyte imbalances, is incorrect as fluid and electrolyte imbalances are not typically direct clinical manifestations of ARDS. While imbalances may occur secondary to the condition or its treatment, they are not the primary clinical features of ARDS. Option D, weight gain, is also incorrect as weight gain is not a typical clinical manifestation of ARDS. In fact, clients with ARDS often experience weight loss due to increased metabolic demands and the catabolic effects of the condition. Educationally, understanding the key clinical manifestations of ARDS is crucial for nurses caring for clients with respiratory conditions. Recognizing dyspnea as a significant sign of hypoxia can prompt timely interventions to improve oxygenation and prevent further deterioration in clients with ARDS. By differentiating between expected and unexpected clinical manifestations, nurses can provide targeted care and support to clients with respiratory distress.

Correct Answer: C

Rationale: In the context of oxygenation and asthma management, it is crucial for nursing students to understand the various triggers that can lead to an acute asthma attack. Selecting the correct answer, which is loud noises (C), demonstrates an understanding of non-typical triggers for asthma exacerbation. Stress (A) is a well-known trigger for asthma attacks due to its impact on the body's stress response system, leading to airway constriction. Animal dander (B) is a common allergen that can provoke asthma symptoms in individuals sensitive to it. Exercise (D) can also trigger asthma attacks due to increased respiratory rate and exposure to environmental factors. Loud noises (C) are not typically associated with asthma exacerbations. While they may cause stress or anxiety in some individuals, they are not a direct physiological trigger for airway constriction or inflammation in asthma patients. Educationally, this question prompts students to critically think about the diverse array of asthma triggers and reinforces the importance of recognizing both common and uncommon factors that can lead to respiratory distress in patients with asthma. Understanding these triggers is essential for providing holistic care and developing effective management strategies for individuals with asthma.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Respiratory therapist. The primary reason for collaborating with a respiratory therapist to maintain the airway of an intubated infant with RSV bronchiolitis is their specialized training and expertise in managing airways and respiratory conditions. Respiratory therapists are skilled in assessing and managing oxygenation, ventilation, and airway patency, making them essential partners in ensuring the infant's respiratory needs are met. The incorrect options are B) Physical therapist, C) Nutritionist, and D) Social worker. Physical therapists focus on mobility, functional abilities, and rehabilitation, which are not directly related to airway management. Nutritionists specialize in dietary needs and planning, which is important but not the primary concern when it comes to maintaining an intubated infant's airway. Social workers provide support and resources for psychosocial needs, but they do not typically have the expertise required for airway management in a critically ill infant. In an educational context, understanding the roles and responsibilities of healthcare team members is crucial for nurses to provide comprehensive care to their patients. Collaborating with the right professionals, such as respiratory therapists in this case, ensures that the infant receives the most appropriate and effective care for their respiratory condition, ultimately leading to better patient outcomes. Nurses must recognize the importance of interdisciplinary collaboration in complex patient care situations to optimize patient safety and well-being.