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A nurse in the emergency department is assisting in the care of a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.

Nurses Notes

1630:

Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender

Vital Signs

1630:

Temperature 38.3°C (101°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Client is short of breath

intercostal retractions visible

Wheezing auscultated throughout lung fields

Diffuse, raised rash present on trunk

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Temperature 38.3°C (101°F)

Client is alert and oriented to person, place, and time.

Heart rate 110/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

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Correct Answer is B

Explanation

A. Excoriation. Excoriation (skin abrasion or scratching) does not indicate a positive tuberculin skin test. A positive reaction is determined by induration (firm swelling) rather than skin irritation or superficial damage. Scratching the site can cause redness, but this is not a diagnostic sign of tuberculosis exposure.

B. Firmness. A positive tuberculin skin test is identified by the presence of induration (firm, raised swelling) at the injection site, which is measured in millimeters. The size of induration considered positive depends on the client’s risk factors. For example, ≥5 mm is positive in immunocompromised individuals, ≥10 mm in high-risk populations, and ≥15 mm in individuals with no risk factors.

C. Ulceration. Ulceration is not a typical reaction to a tuberculin skin test. If ulceration occurs, it may indicate improper injection technique, irritation, or an allergic reaction, rather than a true positive result. The test should be repeated in such cases.

D. Bleeding. Minor pinpoint bleeding at the injection site may occur due to the needle puncture but does not indicate a positive result. The key indicator of a positive test is the presence of measurable induration, not redness, bruising, or bleeding.

A. A pregnant parent B. Receiving treatment for leukemia C. Taking acetaminophen for mild discomfort D. An allergy to eggs

Correct Answer is B

Explanation

A. A pregnant parent. A child can receive the varicella vaccine even if the parent is pregnant. While the varicella vaccine is a live attenuated vaccine, the vaccinated child does not pose a significant risk of transmission to others. The parent should avoid direct contact with the vaccinee's rash if one develops, but this is not a contraindication to immunization.

B. Receiving treatment for leukemia. Children undergoing treatment for leukemia often have weakened immune systems due to chemotherapy or radiation. The varicella vaccine is a live attenuated vaccine, meaning it contains a weakened form of the virus that could cause severe illness in immunocompromised individuals. These children should not receive live vaccines until their immune function improves and their healthcare provider approves vaccination.

C. Taking acetaminophen for mild discomfort. Acetaminophen is an over-the-counter pain reliever and fever reducer that does not interfere with the efficacy or safety of the varicella vaccine. There is no evidence that mild analgesic use before or after vaccination affects immune response, so it is not a reason to withhold the immunization.

D. An allergy to eggs. Unlike some influenza and yellow fever vaccines, the varicella vaccine is not produced using egg-based components. An egg allergy is not a contraindication to receiving the varicella vaccine, as it does not contain egg proteins.

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Body System	Findings
Vital Signs/General History	Temperature 36.4° C (97.6° F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74mm Hg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client varicose veins.
Cardiovascular/ Respiratory	S1 S2 auscultated. No murmurs. All peripheral pulses 2+ Lung sounds clear bilaterally
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odourless. Last menstrual period was 3 months ago
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities

Nursing Test Bank

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A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?

Correct Answer is B

Explanation

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Correct Answer is B

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