1.) A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?
1.A prolonged inspiratory time and a short expiratory time.
2.Frequent productive coughing of clear, frothy, thin mucus progressing to thick, tenacious mucus heard only on auscultation.
3.Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations.
4.Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous.
Answer no. 4
Rationale:
The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
2.) The nurse is performing a breast examination for a nonpregnant woman during her annual gynecological visit. The nurse will be concerned if which one of the following findings is present?
1.Nipple discharge
2.Tail of Spence
3.Soft axilla
4.Consistent patterns of veins
Answer no. 1
Rationale:
Nipple discharge in a woman who is not pregnant or lactating is an abnormal finding during breast examination and should be further evaluated.
3.) Ms. R. is admitted for internal radiation for cancer of the cervix. The nurse knows the client understands the procedure when she makes which of the following remarks the night before the procedure?
1.She says to her husband, “Please bring me a hamburger and french fries tomorrow when you come. I hate hospital food.
2.”I told my daughter who is pregnant to either come to see me tonight or wait until I go home from the hospital.
3.”I understand it will be several weeks before all the radiation leaves my body.
4.”I brought several craft projects to do while the radium is inserted.
Answer no. 2
Rationale:
People who are pregnant should not come in close contact with someone who has internal radiation therapy. The radioactivity could possibly damage the fetus.
4.) The nurse is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is
1.Illumination of the environment.
2.Amount of regular exercise.
3.The resting pulse rate.
4.Status of salt intake.
Answer no. 1
Rationale:
To prevent falls, the environment should be well lighted. Night lights should be used if necessary. Other factors to assess include removing loose scatter rugs, removing spills, and installing handrails and grab bars as appropriate.
5.) Mrs. C. will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4 X 4s, normal saline irrigant, and abdominal pads. Which statement best indicates that Mrs. C. understands the importance of maintaining asepsis?
1.”If I drop the 4 X 4s on the floor, I can use them as long as they are not soiled.
2.”If I drop the 4 X 4s on the floor, I can use them if I rinse them with sterile normal saline.
3.”If I question the sterility of any dressing material, I should not use it.
4.”I should put on my sterile gloves, then open the bottle of saline to soak the 4 X 4s.
Answer no. 3
Rationale:
If there is ever any doubt about the sterility of an instrument or dressing, it should not be used.
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