Question

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Answer 1

Correct Answers:

Last dose and type of rescue inhaler used by the child.

Rationale :

💎 Knowing the last inhaler use helps assess medication effectiveness and potential overdose or failure.

💎 It provides immediate data on bronchodilator response and the need for further intervention.

💎 Timing and type help determine if the attack is refractory to treatment.

💎 Guides the nurse in preparing for possible emergency escalation (e.g., epinephrine or oxygen).

💎 This assessment is time-critical in acute asthma management to evaluate airway stability.

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Answer 2

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🔷 Verification ensures correct type and dose of insulin are used safely.

🔷 Blood glucose testing determines exact insulin needs before administration.

🔷 Drawing insulin after verification avoids contamination and dosing errors.

🔷 Cleansing the site last ensures sterile technique right before injection.

🔷 Correct sequencing prevents hypoglycemia and medication errors.

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Answer 3

Correct Answers:

Maintain the client on an NPO status.

Rationale :

🟢 Vomiting after bariatric surgery signals obstruction or pouch intolerance.

🟢 Keeping the patient NPO prevents further gastric irritation and aspiration risk.

🟢 Bowel rest allows time for inflammation or edema to resolve.

🟢 Supports preparation for diagnostic procedures such as endoscopy if obstruction suspected.

🟢 Early reintroduction of food can lead to anastomotic disruption or leakage.

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Answer 4

Correct Answers:

0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations.

Rationale :

💎 Cushing’s Triad — bradycardia, widened pulse pressure (elevated systolic BP with low diastolic), and irregular respirations — is a classic sign of increased intracranial pressure (ICP).

💎 The combination of decreasing heart rate and increasing blood pressure reflects brainstem compression due to elevated ICP.

💎 Irregular respirations (Cheyne-Stokes or ataxic breathing) occur as ICP affects the medulla’s respiratory center.

💎 These changes signify a neurologic emergency, requiring immediate intervention to prevent brain herniation.

💎 The nurse should notify the healthcare provider at once, prepare for ICP management (e.g., hyperventilation, mannitol, positioning), and monitor for further deterioration.

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Answer 5

Correct Highlights :

Capillary refill is 6 seconds.
No urine noted

Rationale :

💎 Absent urine output indicates decreased renal perfusion due to hypovolemic shock from internal bleeding (likely secondary to liver and splenic lacerations). The kidneys are extremely sensitive to perfusion changes, so no output signals inadequate circulation.

💎 Capillary refill >3 seconds (here 6 seconds) reflects poor peripheral perfusion and decreased cardiac output — a critical sign of progressing shock.

💎 The tachycardia (HR 128) and narrow pulse pressure (90/79) further confirm circulatory compromise and ongoing blood loss.

💎 Despite normal oxygen saturation, tissue perfusion is impaired, emphasizing the need for immediate volume resuscitation and potential transfusion.

💎 Prompt provider notification and implementation of rapid IV fluid and blood replacement are essential to prevent irreversible shock and organ failure.

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Answer 6

Correct Answers:

Electrolytes
Coagulation studies
Complete blood count
Type and screen

Rationale :

🔴 Electrolytes assess fluid balance and resuscitation effect.

🔴 ABG reveals oxygenation and acid-base status.

🔴 Coagulation tests monitor bleeding risks with liver injury.

🔴 CBC shows hemoglobin drop indicating blood loss.

🔴 Type and screen prepares for transfusion if bleeding persists.

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Answer 7

Correct Answers:

Apply warm blankets
Administer intravenous fluids with a rapid infuser
Use a fluid warmer for intravenous fluids

Rationale :

🟡 Warm blankets reduce conductive and convective heat loss.

🟡 Warmed IV fluids prevent further hypothermia from infusion cooling.

🟡 Rapid infusion restores perfusion and stabilizes body temperature.

🟡 Prevents cold-induced coagulopathy that worsens bleeding.

🟡 Maintaining normothermia supports tissue oxygen delivery.

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Answer 8

Correct Answers

Blank 1 Correct Option: Anemia
Blank 2 Correct Option: blood administration/hemodilution from IV fluids

Rationale :

💎 The hemoglobin (9.3 g/dL) and hematocrit (30%) are below normal ranges (12–16 g/dL and 37–47%), confirming anemia.

💎 Liver and spleen lacerations on CT scan indicate internal bleeding, which is the most likely source of the blood loss.

💎 The patient also received a large volume of IV fluids (1,000 mL bolus + maintenance infusion), which can cause hemodilution, further lowering hemoglobin and hematocrit levels.

💎 Stable coagulation times (PT and PTT within normal range) rule out disseminated intravascular coagulation (DIC) as a cause.

💎 Anemia in trauma reduces oxygen-carrying capacity, requiring close monitoring for transfusion needs to restore adequate tissue perfusion and oxygenation.

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Answer 9

Correct Answers:

Explain all procedures
Decrease the noise and light stimuli in the room as much as possible
Assess the client's pain

Rationale :

💎 Explain all procedures – As consciousness returns, the client may feel anxious and disoriented. Providing clear, simple explanations fosters reassurance, reduces fear, and promotes cooperation with care.

💎 Decrease noise and light stimuli – A low-stimulation environment prevents sensory overload, which can increase intracranial pressure (ICP) or agitation in post-trauma or post-sedation clients.

💎Assess the client’s pain – Once the client is more awake, pain assessment becomes crucial. 💎Effective pain control improves recovery and prevents physiologic stress that could worsen ICP or impair healing.

💎 The nurse should not increase propofol without provider order, not consider extubation independently, and not obtain consent (H) retroactively.

💎Decision-making ability is evaluated only after full neurologic recovery.

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Answer 10

Correct Answers

Temperature 98.1°F (36.7°C) [ Prevent Infection ]
PaCO₂ 42 mm Hg [ Support Ventilation ]
PPain 0 on a scale of 0 to 10 [ Control Pain and Anxiety ]
Surgical dressing dry and intact [ Prevent Infection ]
Blood pressure 112/77 mm Hg [ Manage Hypovolemia ]
Capillary refill 2 seconds [ Manage Hypovolemia ]
pH 7.40 [ Support Ventilation ]

Rationale :

💎 Support Ventilation: Normal PaCO₂ (42 mm Hg) and pH (7.40) confirm adequate gas exchange and ventilation.

💎 Control Pain and Anxiety: A pain score of 0 shows effective analgesia and emotional stability.

💎 Manage Hypovolemia: Stable blood pressure and capillary refill <3 seconds demonstrate restored circulatory volume and perfusion.

💎 Prevent Infection: Normal body temperature and a dry, intact surgical dressing indicate effective infection prevention measures.

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Client Data	Support Ventilation	Control Pain and Anxiety	Manage Hypovolemia	Prevent Infection
Temperature 98.1°F (36.7°C)
PaCO₂ 42 mm Hg
PPain 0 on a scale of 0 to 10
Surgical dressing dry and intact
Blood pressure 112/77 mm Hg
Capillary refill 2 seconds
pH 7.40

QLexNursing

1 :
A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

3 :
A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

4 :
Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

5 :
The client is a 24-year-old female who fell while horseback riding.

Correct Highlights :

6 :
The client is a 24-year-old female who fell while horseback riding.

Answer Options

7 :
The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

8 :
The client is a 24-year-old female who fell while horseback riding.

Correct Answers

9 :
The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

10 : Client goal is being met by each of the client data.

Correct Answers

QLexNursing

1 : A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

3 : A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

4 : Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

5 : The client is a 24-year-old female who fell while horseback riding.

Correct Highlights :

6 : The client is a 24-year-old female who fell while horseback riding.

Answer Options

7 : The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

8 : The client is a 24-year-old female who fell while horseback riding.

Correct Answers

9 : The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.

10 : Client goal is being met by each of the client data.

Correct Answers

1 :
A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

3 :
A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

4 :
Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

5 :
The client is a 24-year-old female who fell while horseback riding.

6 :
The client is a 24-year-old female who fell while horseback riding.

7 :
The nurse is concerned about the client's temperature. Which intervention(s) can the nurse use to address the client's temperature? Select all that apply.

8 :
The client is a 24-year-old female who fell while horseback riding.

9 :
The client has started to wake up more, opening her eyes without stimulation and looking around the room. Which should the nurse do as the client becomes more aware of her surroundings? Select all that apply.