Exhibits
Which physical sign most strongly supports the nurse's concern for worsening asthma?
Normal temperature
Slightly elevated heart rate
Nasal flaring and intercostal retractions
Use of maintenance inhaler
The Correct Answer is C
A. Normal temperature: A temperature of 98.6°F (37°C) is within the normal range and does not contribute to the assessment of asthma severity. It helps rule out infection but does not reflect worsening respiratory status.
B. Slightly elevated heart rate: A heart rate of 122 bpm is elevated for a 7-year-old and may indicate respiratory distress or anxiety. However, it is a nonspecific finding and not the strongest indicator of worsening asthma.
C. Nasal flaring and intercostal retractions: These are classic signs of increased work of breathing and indicate significant respiratory distress. They reflect worsening airway obstruction and the need for immediate intervention to prevent further deterioration.
D. Use of maintenance inhaler: Use of a maintenance inhaler such as fluticasone is part of routine asthma management and does not indicate worsening symptoms. It is a preventive measure, not a reflection of acute status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Nasal cannula:The nasal cannula provides low-flow oxygen with variable concentrations depending on the patient's respiratory rate and tidal volume. It does not deliver a precise or consistent oxygen concentration.
B. Simple face mask:The simple face mask delivers moderate concentrations of oxygen, generally between 40–60%, but it lacks a mechanism for precise control. Oxygen delivery fluctuates based on the patient’s breathing pattern and flow rate.
C. Venturi mask:The Venturi mask is designed to deliver a specific and consistent concentration of oxygen by using color-coded adaptors that mix oxygen with room air at fixed ratios. This makes it ideal for patients who require accurate oxygen titration, such as those with COPD.
D. Non-rebreather mask:A non-rebreather mask delivers high concentrations of oxygen (up to 90–100%) but does not allow for fine control of the exact oxygen percentage. It is used in emergencies when high oxygen delivery is needed, not for precise regulation.
Correct Answer is B
Explanation
A. The client's sodium and chloride levels will rise:CO₂ retention affects acid-base balance more directly than it affects electrolyte concentrations like sodium or chloride. Changes in these levels may occur in severe or chronic cases, but they are not the initial response.
B. The client's arterial blood gas results will reflect acidosis:When CO₂ accumulates in the blood due to hypoventilation, it forms carbonic acid, lowering blood pH. This results in respiratory acidosis, which is typically the earliest and most direct physiological response to CO₂ retention.
C. The client will lose consciousness:Loss of consciousness may occur if CO₂ levels rise dramatically and go uncorrected. However, this is a late sign of severe respiratory failure, not the initial or most sensitive indicator.
D. The client will complain of facial numbness and tingling:These symptoms are more characteristic of respiratory alkalosis, often due to hyperventilation, not CO₂ retention. In respiratory acidosis, symptoms are more likely to include drowsiness, confusion, or headache.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.