A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is afebrile, heart rate 96 beats/minute, respirations 32 breaths/minute, and pulse oximeter reading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expirations. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

Pneumonia.

Pneumothorax.

Asthma.

Bronchitis.

Answer and Explanation

The Correct Answer is C

A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.

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Correct Answer is A

Explanation

A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.
B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.
C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.
D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.

A. An area of erythema that is painful to touch. B. Shallow open ulcer with a red pink wound bed. C. A deep pocket of infection and necrotic tissues. D. Visible subcutaneous tissue with sloughing.

Correct Answer is B

Explanation

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is A

Explanation

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is B

Explanation

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?