A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

Premature Ventricular Contractions (PVC's)

Respiratory Rate of 14 / min

Circumoral cyanosis

Retraction of sternal muscles

SpO2 95%

Answer and Explanation

Correct Answer : C,D

A.   Premature Ventricular Contractions (PVC's) (A) are related to cardiac activity and not directly indicative of respiratory function.
B.   A respiratory rate of 14 breaths per minute is within the normal range for adults (12-20 breaths per minute). Therefore, this finding does not indicate a decline in respiratory status.
C.   Circumoral cyanosis, which refers to a bluish discoloration around the mouth, indicates hypoxia and is a sign of deteriorating respiratory status. It suggests that the body is not getting enough oxygen, which is critical to monitor in an asthma attack.
D.   Retractions, especially of the sternal muscles, are a sign of increased work of breathing and can indicate severe respiratory distress. This finding suggests that the patient is struggling to breathe effectively, indicating a decline in respiratory status.
E.   An SpO2 of 95% is generally considered acceptable, especially in patients with asthma, as normal oxygen saturation levels typically range from 95% to 100%. While it is at the lower end of normal, it does not indicate an immediate decline in respiratory status.

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Correct Answer is D

Explanation

A. While patients with latent TB may be treated to prevent progression to active TB, the treatment duration is generally shorter—typically around 3 to 9 months, depending on the medication regimen (e.g., isoniazid for 9 months or rifampin for 4 months).
B. Individuals with latent TB will usually test positive on a Mantoux test (also known as a tuberculin skin test), indicating they have been exposed to the TB bacteria. However, those with latent TB do not have active disease and may not have symptoms.
C. Individuals with latent TB do not spread the bacteria to others because the infection is contained and does not cause active disease. Only those with active TB can transmit the bacteria, regardless of sputum test results.
D. Patients with latent TB are not contagious and cannot spread the bacteria to others. The bacteria remain inactive in the body, and only a small percentage of these individuals may develop active TB in the future.

A. Anemia B. Pancytopenia C. Neutropenia D. Leukopenia

Correct Answer is B

Explanation

A. While anemia is a common finding in aplastic anemia, it is not the most comprehensive answer. Aplastic anemia results in a deficiency of all blood cell types due to bone marrow failure, so while anemia is present, it does not fully capture the extent of the disorder.
B. This is the most accurate choice. Pancytopenia refers to the simultaneous reduction of red blood cells, white blood cells, and platelets. In aplastic anemia, the bone marrow fails to produce adequate blood cells, leading to this triad of cytopenias, making it the hallmark of the disease.
C. Neutropenia, which is a low level of neutrophils (a type of white blood cell), can occur in aplastic anemia. However, it is only one component of the broader condition and does not represent the complete picture of the disease.
D. Leukopenia refers to a low white blood cell count. Like neutropenia, it can be a finding in aplastic anemia, but it does not encompass the anemia and thrombocytopenia that also occur.

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A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a nurse, you understand that when patients have latent TB:

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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