Question

A school nurse is caring for a school age child who has asthma.

Answer 1

Correct Highlights :

Administer acetaminophen
Have the child wear a mask
Encourage oral fluids
Administer albuterol nebulizer
Evaluate the child's peak flow
Have the child sit upright in a position of comfort

Rationale :

✅ Administer acetaminophen

💠 A temperature of 39.9°C (103.8°F) indicates a high fever, which increases metabolic demand and oxygen consumption.

💠 Acetaminophen is appropriate to reduce fever and discomfort and prevent febrile complications.

✅ Have the child wear a mask

💠 The sudden fever with cough suggests a possible infectious process.

💠 Masking reduces transmission of respiratory pathogens in the school environment.

✅ Encourage oral fluids

💠 Fever increases insensible fluid loss, placing the child at risk for dehydration.

💠 Adequate hydration also helps thin respiratory secretions and supports immune response.

Administer a dose of montelukast

💠 Montelukast is a long-term asthma control medication, not indicated for acute changes or fever management.

✅ Administer albuterol nebulizer

💠 Increased respiratory rate (26/min) and cough suggest acute bronchoconstriction.

💠 Albuterol provides rapid bronchodilation, relieving airway narrowing.

✅ Evaluate the child’s peak flow

💠 Peak flow measurement helps assess severity of airway obstruction and response to treatment.

💠 It is appropriate for school-age children with asthma.

✅ Have the child sit upright in a position of comfort

💠 Upright positioning improves lung expansion and ventilation.

💠 It decreases work of breathing and supports airway patency.

Initiate chest percussions

💠 Chest percussion is used for conditions with thick secretions (e.g., cystic fibrosis).

💠 It is not indicated for asthma exacerbation

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Answer 2

Correct Answers:

Raise the height of the client's bed.

Rationale :

💠 Raising the bed to waist level is the first action because it prevents back strain and musculoskeletal injury to the nurse.

💠 Proper bed height allows the nurse to maintain neutral spine alignment and use leg muscles effectively.

💠 Injury prevention for the nurse is a safety priority and must occur before repositioning begins.

💠 Failing to adjust bed height increases the risk of acute and cumulative lower-back injury.

💠 Safe body mechanics protect both the nurse and the client during movement.

Tighten their abdominal muscles.

💠 Core engagement is important but should occur after proper bed height is set.

💠 Abdominal tightening alone does not correct poor body positioning.

Place their feet in line with their shoulders.

💠 Foot placement improves balance but is done after environmental setup.

💠 Proper stance is ineffective if the bed height is incorrect.

Pivot their feet in the direction of the move.

💠 Pivoting is used during movement, not as the initial step.

💠 This action assumes the nurse is already positioned safely.

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Answer 3

Correct Answers:

Decreased pulmonary compliance due to stiffness

Rationale :

💠 In acute respiratory distress syndrome (ARDS), widespread alveolar inflammation and fluid accumulation cause the lungs to become stiff and noncompliant.

💠 Damage to the alveolar–capillary membrane leads to surfactant loss, resulting in alveolar collapse (atelectasis).

💠 As compliance decreases, the lungs require higher pressures to expand, significantly increasing the work of breathing.

💠 This stiffness is a defining pathophysiologic feature of ARDS and explains the need for mechanical ventilation with PEEP.

💠 Reduced compliance directly contributes to severe hypoxemia that is refractory to oxygen therapy.

Hypoxemia due to dead space

💠 ARDS hypoxemia is primarily caused by intrapulmonary shunting, not dead space.

💠 Blood passes through non-ventilated alveoli, preventing oxygenation.

Decreased pulmonary arterial pressure due to V/Q mismatch

💠 ARDS often causes increased pulmonary pressures due to hypoxic vasoconstriction.

💠 Pulmonary arterial pressure does not decrease in this condition.

Impaired carbon dioxide elimination due to shunting

💠 Early ARDS primarily affects oxygenation, not carbon dioxide removal.

💠 CO₂ diffuses more easily and is usually eliminated until late stages.

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Answer 4

Correct Answers:

Depression

Rationale :

💠 Clients with osteoarthritis who have chronic pain and impaired mobility often experience loss of independence, which strongly contributes to depressive symptoms.

💠 Being unable to leave the house leads to social isolation, reduced social roles, and feelings of hopelessness or worthlessness.

💠 Depression is a common psychosocial consequence of chronic musculoskeletal disease and directly affects quality of life and treatment adherence.

💠 Unlike temporary mood changes, depression requires further evaluation and intervention, such as counseling or pharmacologic therapy.

💠 Early identification allows the nurse to initiate mental health support and community resources.

Cognitive impairment

💠 Osteoarthritis does not directly cause cognitive decline.

💠 Cognitive changes suggest a neurologic condition, not a psychosocial impact of mobility loss.

Insomnia

💠 Sleep disturbance is common with chronic pain but is a physical symptom, not primarily psychosocial.

💠 Insomnia alone does not indicate emotional maladjustment.

Cardiovascular disease

💠 Cardiovascular disease is a physical comorbidity, not a psychosocial effect.

💠 It does not reflect the emotional impact of being homebound.

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Answer 5

Correct Answers:

The pancreas's location increases the risk that cancer will spread into nearby structures and blood vessels.

Rationale :

💠 The pancreas lies deep in the abdomen, close to major blood vessels (e.g., superior mesenteric vessels) and vital organs, which facilitates early local invasion and metastasis.

💠 Because of this location, pancreatic cancer often produces few early symptoms, leading to late diagnosis when spread has already occurred.

💠 Tumor growth can readily extend into adjacent tissues and the vascular system, complicating surgical resection.

💠 This anatomic reality explains why pancreatic cancer has a poor prognosis compared with many other cancers.

💠 Educating clients about this helps set realistic expectations for treatment planning and outcomes.

Pancreatic cancers are classified as either endocrine, pancreatic cancer or exocrine pancreatic cancer.

💠 The correct classification is endocrine pancreatic tumors vs exocrine pancreatic tumors; the option is incorrectly stated.

Pancreatic cancer typically develops from a polyp.

💠 Polyps are associated with colorectal cancer, not pancreatic cancer.

💠 Pancreatic cancer usually arises from ductal cells (exocrine).

Pancreatic cancer is distinguished based on the layers of the pancreas.

💠 Staging is based on tumor size, lymph node involvement, and metastasis, not pancreatic layers.

💠 Layer-based classification applies to some GI cancers, not pancreatic cancer.

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Answer 6

Correct Answers:

Prealbumin level
History of diabetes mellitus
Wound infection
Decreased pedal perfusion
Fasting blood glucose

Rationale :

💠 Prealbumin level

Low prealbumin (8 mg/dL) reflects poor protein status, which directly impairs collagen synthesis, immune response, and tissue repair. Protein deficiency is one of the strongest predictors of delayed wound healing.

💠 History of diabetes mellitus

Diabetes causes microvascular damage, impaired leukocyte function, and reduced oxygen delivery, all of which slow wound healing. Diabetic clients are also at higher risk for infection.

💠 Wound infection

An elevated WBC count (14,500/mm³) with surrounding erythema indicates infection, which prolongs the inflammatory phase and prevents progression to tissue repair.

💠 Decreased pedal perfusion

A 1+ pedal pulse indicates reduced blood flow, leading to inadequate delivery of oxygen, nutrients, and immune cells necessary for healing.

💠 Fasting blood glucose

Persistent hyperglycemia (144–186 mg/dL) interferes with fibroblast activity, collagen formation, and immune defense, significantly delaying wound closure.

💠 Potassium level

Potassium values are within normal range and do not directly affect wound healing.

💠 History of hyperlipidemia

Hyperlipidemia contributes to long-term vascular disease but is not an immediate or direct cause of delayed wound healing in this scenario.

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Answer 7

Correct Answers:

Decreased cardiac output

Rationale :

💠 Tracheal deviation in tension pneumothorax indicates severe intrapleural pressure buildup, which compresses the heart and great vessels.

💠 This pressure markedly reduces venous return to the heart, limiting preload and impairing cardiac filling.

💠 As preload drops, cardiac output decreases, leading to hypotension, shock, and possible cardiac arrest if untreated.

💠 The deviation reflects mediastinal shift, a hallmark of tension pneumothorax requiring immediate decompression.

💠 This mechanism explains why tension pneumothorax is a medical emergency prioritized under ABCs.

Increased venous return

💠 Venous return is decreased, not increased, due to compression of the vena cava.

Respiratory alkalosis

💠 Early respiratory changes may occur, but alkalosis is not the defining consequence of tracheal deviation.

💠 Hypoxia and hemodynamic collapse are the primary concerns.

Dilated ventricles

💠 Ventricular dilation requires adequate filling, which does not occur when venous return is compromised.

💠 Compression leads to underfilled, not dilated, ventricles.

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Answer 8

Correct Answers:

Optimize functional status

Rationale :

💠 Stroke rehabilitation aims to help the client achieve the highest possible level of function, not a complete return to baseline.

💠 The extent of neurologic recovery varies, and setting realistic, achievable goals promotes motivation and participation in therapy.

💠 Focusing on optimizing function supports improvement in mobility, self-care, communication, and safety using adaptive strategies as needed.

💠 This goal aligns with interdisciplinary rehab planning, including physical, occupational, and speech therapy.

💠 Realistic goals reduce frustration and help the client adjust to long-term recovery expectations.

Achieve pre-stroke function

💠 Full return to pre-stroke status is often unrealistic and may set the client up for disappointment.

💠 Recovery depends on stroke severity and location.

Maintain full independence

💠 Some clients will require assistance or adaptive devices despite optimal rehabilitation.

💠 Independence may be partial rather than complete.

Determine if the client can return to their home

💠 This is a discharge planning consideration, not a rehabilitation goal.

💠 It does not directly address functional improvement.

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Answer 9

Correct Answers:

Respiratory acidosis

Rationale :

💠 In chronic obstructive pulmonary disease (COPD), airflow limitation leads to hypoventilation, causing carbon dioxide (CO₂) retention.

💠 Elevated CO₂ increases carbonic acid in the blood, resulting in respiratory acidosis.

💠 Clients who are short of breath often have worsening ventilatory impairment, intensifying CO₂ buildup.

💠 Over time, the kidneys may partially compensate by retaining bicarbonate, but the primary disorder remains respiratory.

💠 ABGs in COPD typically show ↓ pH, ↑ PaCO₂, confirming respiratory acidosis.

Respiratory alkalosis

💠 This occurs with hyperventilation, which lowers CO₂.

💠 COPD limits ventilation rather than increasing it.

Metabolic alkalosis

💠 Metabolic alkalosis is related to loss of acids or excess bicarbonate, not lung disease.

💠 It is not the primary ABG pattern in COPD.

Metabolic acidosis

💠 Metabolic acidosis involves bicarbonate loss or acid gain, usually from renal or metabolic causes.

💠 It does not reflect impaired gas exchange.

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Answer 10

Correct Answers:

Auscultate the client's apical pulse.

Rationale :

💠 With an irregular heart rate, peripheral pulses may be uneven or missed, making them unreliable for accurate assessment.

💠 Auscultating the apical pulse directly measures the heart’s electrical and mechanical activity at the point of maximal impulse.

💠 This method allows the nurse to detect irregular rhythms, extra beats, or pulse deficits.

💠 Accurate apical assessment is essential before administering cardiac medications (e.g., digoxin, beta-blockers).

💠 Standard practice is to auscultate the apical pulse for a full 60 seconds in irregular rhythms.

Palpate the client’s pulse at the third intercostal space.

💠 Pulses are not palpated at intercostal spaces.

💠 This reflects incorrect anatomical technique.

Check the client’s heart rate for 30 seconds.

💠 Shortened counting can miss irregular beats.

💠 Irregular rhythms require a full minute for accuracy.

Ask the client to perform the Valsalva maneuver.

💠 Valsalva is a therapeutic intervention, not an assessment action.

💠 It should only be done with a provider’s order.

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Lab Test	Day 1 Result (0630)	Day 4 Result (0630)	Reference Range
Hematocrit (Hct)	38%	38%	37% to 47%
Hemoglobin (Hgb)	13 g/dL	14 g/dL	12 to 16 g/dL
White Blood Cell (WBC)	11,500/mm³	14,500/mm³	5,000 to 10,000/mm³
Potassium	3.6 mEq/L	3.5 mEq/L	3.5 to 5.0 mEq/L
Pre-albumin	10 mg/dL	8 mg/dL	15 to 36 mg/dL
Albumin	3.0 g/dL	3.0 g/dL	3.5 to 5.0 g/dL
Fasting Blood Glucose	186 mg/dL	144 mg/dL	74 to 106 mg/dL

QLexNursing

1 :
A school nurse is caring for a school age child who has asthma.

Correct Highlights :

2 :
A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 :
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

4 :
A nurse is providing care to a client who has osteoarthritis and is experiencing difficulty with mobility and cannot leave their house. Which of the following psychosocial health impacts is expected and requires further evaluation?

5 :
A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

6 :
A nurse is caring for a client.

Answer Options

7 :
A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

8 :
A client is beginning inpatient rehabilitation after experiencing a stroke. A nurse is working with the client during this transition and helping to set realistic goals. Which of the following is the most appropriate goal for this client?

9 :
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood games (ABGS), which of the following conditions should the nurse anticipate the client to be experiencing?

10 :
A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

QLexNursing

1 : A school nurse is caring for a school age child who has asthma.

Correct Highlights :

2 : A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 : A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

4 : A nurse is providing care to a client who has osteoarthritis and is experiencing difficulty with mobility and cannot leave their house. Which of the following psychosocial health impacts is expected and requires further evaluation?

5 : A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

6 : A nurse is caring for a client.

Answer Options

7 : A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

8 : A client is beginning inpatient rehabilitation after experiencing a stroke. A nurse is working with the client during this transition and helping to set realistic goals. Which of the following is the most appropriate goal for this client?

9 : A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood games (ABGS), which of the following conditions should the nurse anticipate the client to be experiencing?

10 : A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

1 :
A school nurse is caring for a school age child who has asthma.

2 :
A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

3 :
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

4 :
A nurse is providing care to a client who has osteoarthritis and is experiencing difficulty with mobility and cannot leave their house. Which of the following psychosocial health impacts is expected and requires further evaluation?

5 :
A nurse is educating a client about a recent diagnosis of pancreatic cancer. Which of the following information should the nurse include in the client education?

6 :
A nurse is caring for a client.

7 :
A nurse is assessing a client who has tension pneumothorax. Which of the following findings should the nurse expect following tracheal deviation?

8 :
A client is beginning inpatient rehabilitation after experiencing a stroke. A nurse is working with the client during this transition and helping to set realistic goals. Which of the following is the most appropriate goal for this client?

9 :
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath. When reviewing the client's arterial blood games (ABGS), which of the following conditions should the nurse anticipate the client to be experiencing?

10 :
A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?