The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?

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Question 1 of 5

The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately?

Correct Answer: B

Rationale: Sudden absence of wheezes in one lobe needs immediate provider call. It suggests airway obstruction or pneumothorax, life-threatening in asthma. Inspiration , sputum , and muscles are less urgent. B signals crisis, making it priority.

Question 2 of 5

What finding signifies that children have attained the stage of concrete operations (Piaget)?

Correct Answer: C

Rationale: Stealing is wrong' signifies concrete operations (7-11 years). Moral judgment reflects logical thinking, per Piaget. Exploration , images , and reasoning fit earlier stages. C matches development, making it correct.

Question 3 of 5

The nurse has just received a client from the emergency department who experienced blunt chest trauma in a motor vehicle crash. Which assessment finding requires immediate intervention by the nurse?

Correct Answer: D

Rationale: Trachea deviated to the right requires immediate intervention. It suggests tension pneumothorax from trauma, shifting mediastinum, needing urgent decompression per ABCs. Tachypnea , SpO2 94% , and bruising are less acute. D threatens airway, making it priority.

Question 4 of 5

The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy at 2 L/min via nasal cannula. Which finding would be of most concern to the nurse?

Correct Answer: D

Rationale: Pulse rate of 100 is most concerning with new oxygen in COPD. Tachycardia may signal hypoxia or distress, needing prompt evaluation, per ABCs. RR 20 , SpO2 90% , and dyspnea are typical. D indicates instability, making it priority.

Question 5 of 5

The nurse is preparing to administer a medication via intramuscular injection. Which action should the nurse take to ensure client safety?

Correct Answer: A

Rationale: Aspirating after needle insertion ensures safety in IM injections. Blood return indicates vessel entry, preventing IV administration, per protocol. Quick injection risks tissue damage, 22-gauge varies by drug, and vigorous massage spreads medication. A prevents harm, making it key.

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