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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is a crucial action following a bone marrow biopsy, as there is a risk of bleeding at the biopsy site. Monitoring for signs of bleeding or hematoma formation is essential to prevent complications, making this a highly appropriate nursing action.
B. While applying heat may provide comfort, it is generally not recommended immediately after a biopsy because it can increase blood flow to the area and potentially exacerbate bleeding. Thus, this action may not be appropriate right after the procedure.
C. While some level of rest is important after a procedure, keeping the patient NPO (nothing by mouth) is unnecessary unless there are specific orders due to anesthesia or other considerations. Additionally, remaining bedbound could increase discomfort or risk of complications like deep vein thrombosis (DVT) if not warranted.
D. Aspirin should be avoided in this scenario because it is an anticoagulant and can increase the risk of bleeding, particularly after a procedure like a bone marrow biopsy. Instead, other pain management strategies that do not affect clotting should be considered.

A. Neutrophils B. Lymphocytes C. Basophils D. Eosinophils

Correct Answer is B

Explanation

A. Neutrophils are the most abundant type of WBC and are primarily involved in responding to bacterial infections. While they may increase during a viral infection, their primary function is to combat bacteria and fungi. Therefore, they are not the most specific indicator of viral illnesses.
B. Lymphocytes, which include T cells and B cells, are the most directly associated with viral infections. They play a crucial role in the adaptive immune response, recognizing and responding to viral pathogens. A significant increase in lymphocytes, particularly T cells, is commonly seen during viral infections.
C. Basophils are involved in allergic reactions and responses to parasites, releasing histamine and other mediators. They are not significantly involved in the response to viral infections and typically do not show a notable increase in these situations.
D. Eosinophils primarily respond to parasitic infections and allergic reactions. While they may be elevated in some allergic conditions and certain parasitic infections, they are not directly involved in the immune response to viral infections.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Your patient has suspected aplastic anemia and has just returned to the unit to be cared for by you after having bone marrow biopsy done to confirm the diagnosis. Which of the following is the MOST appropriate nursing action?

Correct Answer is A

Explanation

The medical team believes that your patient has been suffering from a severe Viral infection, and has ordered blood to be drawn for laboratory analysis. You know that which of the following types of white blood cells is MOST associated with a Viral illness?

Correct Answer is B

Explanation

A nurse is caring for a client who has a WBC count of 22,000. The nurse should conclude that the client has which of the following?

You are planning to transfuse a unit of PRBC's to your patient. You know that when you arrive at the blood bank and they hand you the unit of blood, you have how long to start the transfusion from that time?

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.)

A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). The client reports fatigue, joint tenderness, swelling, and difficulty urinating. Which of the following laboratory findings should the nurse anticipate? (Select all that apply)

A nurse is assessing a client who has a new diagnosis of SLE (Lupus). Which of the following findings should the nurse expect?

Your patient had an open colon resection a week ago and developed a subsequent infection of their surgical incision. Now the patient's blood pressure has been dropping for the past 2 hours and is currently 89/65. What type of shock is the patient experiencing?