Question

A nurse receives report on four clients. Which client should the nurse assess first?

Answer 1

Correct Answers:

A client with asthma who has a respiratory rate of 32 breaths per minute and audible wheezing.

Rationale :

✨ Tachypnea at 32 breaths/min with audible wheezing indicates significant respiratory distress and possible worsening bronchospasm.

✨ In asthma, narrowing of the airways can rapidly progress and compromise oxygenation and ventilation.

✨ The nurse should prioritize using the ABCs: airway, breathing, circulation.

✨ Audible wheezing suggests marked airflow obstruction, and the elevated respiratory rate shows the client is working harder to breathe.

✨ Asthma can deteriorate quickly into status asthmaticus or respiratory failure if bronchospasm is not relieved.

✨ This client requires immediate assessment of oxygen saturation, breath sounds, work of breathing, ability to speak, and response to bronchodilator therapy.

✨ The nurse should also watch for a silent chest, decreasing level of consciousness, or exhaustion, which can signal impending respiratory failure.

✨ Therefore, this client has the most acute breathing problem and should be assessed first.

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Answer 2

Correct Answers:

Stridor

Rationale :

✳️ Stridor is a high-pitched respiratory sound caused by significant narrowing or obstruction of the upper airway.

✳️ When stridor develops shortly after an IV antibiotic is started, the nurse should suspect a severe hypersensitivity reaction, potentially anaphylaxis.

✳️ Anaphylaxis can cause laryngeal and upper-airway edema, rapidly compromising the client's ability to breathe.

✳️ Using the ABC priority framework, airway compromise takes priority over skin and gastrointestinal manifestations.

✳️ Because IV medications enter the circulation directly, a severe allergic reaction can develop very rapidly.

✳️ The nurse should stop the antibiotic infusion immediately, maintain IV access with appropriate compatible fluid per protocol, and initiate emergency interventions.

✳️ IM epinephrine is the first-line medication for anaphylaxis, with airway support and oxygen provided as clinically indicated.

✳️ Therefore, stridor is the most concerning finding because it indicates potentially life-threatening airway obstruction.

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Answer 3

Correct Answers:

Serum potassium 5.3 mEq/L

Rationale :

🎯 These ABG results indicate metabolic acidosis with respiratory compensation: pH 7.29 ↓, HCO₃⁻ 20 mEq/L ↓, and PaCO₂ 30 mm Hg ↓.

🎯 In metabolic acidosis, excess hydrogen ions (H⁺) accumulate in the extracellular fluid.

🎯 As part of buffering, hydrogen ions move into cells, and potassium (K⁺) may shift out of cells into the bloodstream.

🎯 This transcellular shift can produce an elevated serum potassium level (hyperkalemia), although the degree depends on the cause of the acidosis.

🎯 A potassium level of 5.3 mEq/L is mildly elevated and is therefore the finding most consistent with the acid-base disturbance presented.

🎯 The nurse should monitor potassium carefully because significant hyperkalemia can cause cardiac conduction abnormalities and dysrhythmias.

🎯 The decreased PaCO₂ of 30 mm Hg shows that the lungs are compensating by increasing ventilation and eliminating CO₂.

🎯 Therefore, among the options, serum potassium 5.3 mEq/L is the most anticipated additional finding.

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Answer 4

Correct Answers:

A client who has sepsis.

Rationale :

🧿 Sepsis places a client at significant risk for metabolic acidosis, particularly lactic acidosis.

🧿 Severe sepsis can cause systemic vasodilation, hypotension, and impaired tissue perfusion, reducing oxygen delivery to tissues.

🧿 When cells receive inadequate oxygen, they increasingly rely on anaerobic metabolism.

🧿 Anaerobic metabolism leads to increased production and accumulation of lactic acid (lactate).

🧿 Accumulation of metabolic acids consumes bicarbonate, causing the serum HCO₃⁻ level to decrease.

🧿 As metabolic acidosis develops, the blood pH falls below 7.35.

🧿 The respiratory system attempts to compensate by increasing ventilation and eliminating CO₂, which lowers the PaCO₂.

🧿 Therefore, a client with sepsis is at risk for lactic acidosis → metabolic acidosis, especially when tissue hypoperfusion is present.

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Answer 5

Correct Answers:

Respiratory rate 7 breaths/minute

Rationale :

🍊 Respiratory acidosis occurs when inadequate ventilation causes the body to retain carbon dioxide (CO₂), increasing carbonic acid and lowering blood pH.

🍊 A respiratory rate of 7 breaths/minute indicates severe bradypnea and hypoventilation.

🍊 Hypoventilation causes additional CO₂ retention, which can rapidly worsen the client's respiratory acidosis.

🍊 A rate this low may indicate significant respiratory depression and possible progression toward respiratory failure.

🍊 Using the ABC framework, breathing takes priority over cardiovascular and neurologic findings.

🍊 The nurse should immediately assess airway patency, oxygenation, respiratory depth, level of consciousness, and potential causes of respiratory depression.

🍊 Severe CO₂ retention can cause CO₂ narcosis, producing worsening confusion, somnolence, decreased consciousness, and eventually coma.

🍊 Therefore, a respiratory rate of 7 breaths/minute is the most concerning finding because it indicates potentially life-threatening inadequate ventilation.

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Answer 6

Correct Answers:

Hypothermia

Rationale :

🌸 Older adults with pneumonia may have an atypical presentation and may not develop the high fever commonly expected with infection.

🌸 Because aging can produce a reduced thermoregulatory and immune response, an older adult may develop a normal or even decreased body temperature despite significant infection.

🌸 Hypothermia can therefore be an important manifestation of serious infection in an older adult.

🌸 Other atypical manifestations can include acute confusion, weakness, lethargy, decreased appetite, and functional decline.

🌸 Changes in mental status may sometimes occur before obvious respiratory manifestations, making careful assessment important.

🌸 Older adults can still develop typical pneumonia findings such as cough, dyspnea, tachypnea, crackles, and hypoxemia, but these may be less pronounced.

🌸 A low temperature in an older adult with suspected infection should not be interpreted as evidence that infection is absent.

🌸 Therefore, among the choices provided, hypothermia is the expected manifestation most associated with the atypical presentation of pneumonia in an older adult.

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Answer 7

Correct Answers:

Assist the client into an upright position,
Place the client on oxygen via nasal cannula.
Administer an albuterol nebulizer as ordered.

Rationale :

✅ Assist the client into an upright position

🌻 Placing the client in an upright or high-Fowler's position promotes maximal lung expansion.

🌻 Upright positioning allows the diaphragm to descend more effectively, improving ventilation.

🌻 It can decrease the work of breathing in a client experiencing respiratory distress.

🌻 The client's intercostal retractions indicate increased respiratory effort, making positioning an important immediate intervention.

🌻 The nurse should avoid positioning the client flat because this can make breathing more difficult.

🌻 Clients experiencing severe dyspnea may naturally prefer sitting upright or leaning slightly forward to facilitate breathing.

🌻 Positioning is a rapid, noninvasive intervention that can be implemented while other respiratory treatments are being prepared.

🌻 Therefore, assisting the client into an upright position is appropriate.

✅ Place the client on oxygen via nasal cannula

🌻 An oxygen saturation of 88% on room air indicates significant hypoxemia and requires supplemental oxygen.

🌻 Supplemental oxygen increases the amount of oxygen available for gas exchange at the alveolar level.

🌻 A nasal cannula can provide supplemental oxygen while allowing the client to receive other treatments and communicate.

🌻 The nurse should monitor SpO₂ continuously or frequently and assess the client's response to oxygen therapy.

🌻 Oxygen delivery should be titrated according to the client's condition, prescribed target, and emergency protocol.

🌻 If a nasal cannula does not adequately correct the hypoxemia, a higher-concentration oxygen-delivery device may be required.

🌻 Correcting hypoxemia is a priority because prolonged inadequate oxygenation can impair organ and tissue function.

🌻 Therefore, supplemental oxygen should be initiated promptly.

✅ Administer an albuterol nebulizer as ordered

🌻 Albuterol is a short-acting beta₂-adrenergic agonist (SABA) commonly used as a rescue medication during acute asthma exacerbations.

🌻 It stimulates beta₂ receptors in bronchial smooth muscle, producing bronchodilation.

🌻 Bronchodilation helps open narrowed airways and improves air movement and ventilation.

🌻 Albuterol should help reduce wheezing, dyspnea, and increased work of breathing.

🌻 Nebulized administration allows the medication to reach the respiratory tract while the client continues breathing normally through the treatment.

🌻 The nurse should reassess breath sounds, respiratory rate, work of breathing, and oxygen saturation after treatment.

🌻 The nurse should also monitor for common adverse effects such as tachycardia, tremor, and nervousness.

🌻 Because this client demonstrates acute bronchospasm, administering the prescribed albuterol nebulizer is a priority intervention.

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Answer 8

Correct Answers:

Active natural immunity

Rationale :

🌼 Active natural immunity develops when a person is naturally exposed to a pathogen and their own immune system responds to the infection.

🌼 When a person becomes infected with measles virus, the immune system recognizes viral antigens as foreign.

🌼 The person's immune system actively produces specific antibodies against the measles virus.

🌼 The immune response also generates memory B and T cells, which can respond rapidly if the virus is encountered again.

🌼 This immunity is considered active because the person's own immune system produces the immune response.

🌼 It is considered natural because exposure occurs through natural infection, rather than vaccination or administration of antibodies.

🌼 Active immunity generally develops more slowly than passive immunity but typically provides long-lasting protection.

🌼 Therefore, immunity acquired after actually becoming sick with measles is classified as active natural immunity.

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Answer 9

Correct Answers

Encourage the client to perform personal hygiene care daily. [ Anticipated ]
Place the client in a negative air pressure room. [ not anticipated ]
Teach the client to increase their fluid intake to prevent constipation. [ Anticipated ]
Educate the client to avoid the use of tampons during their period. [ Anticipated ]
Show the client how to use an electric razor for shaving. [ not anticipated ]
Do not allow any visitors to enter the client's room. [ not anticipated ]

Rationale :

✅ Encourage the client to perform personal hygiene care daily — Anticipated

♠️ A client with neutropenia has a reduced ability to fight infection because the number of circulating neutrophils is decreased.

♠️ Daily hygiene helps decrease the number of microorganisms present on the skin, lowering the chance that bacteria will enter the body.

♠️ The client should perform regular bathing, oral care, and perineal care because these areas can become common sources of infection.

♠️ The nurse should encourage gentle care of the skin because cuts, abrasions, and skin breakdown can become portals of entry for microorganisms.

♠️ Oral hygiene is especially important because neutropenic clients can develop mouth sores, gingival irritation, and oral infections.

♠️ A soft toothbrush is generally preferred to reduce trauma to the gums while still maintaining cleanliness.

♠️ Perineal hygiene should be performed carefully, especially after bowel movements, because bacteria from the gastrointestinal tract can cause serious infection.

♠️ Therefore, daily personal hygiene is an important component of neutropenic infection prevention.

❌ Place the client in a negative air pressure room — Not Anticipated

A negative-pressure room is primarily used for clients who have airborne infections such as tuberculosis, measles, or varicella.

Negative pressure protects people outside the room by keeping contaminated airborne particles from escaping, whereas a neutropenic client may instead require a protective environment, sometimes including positive-pressure airflow, depending on severity and facility policy.

✅ Teach the client to increase fluid intake to prevent constipation — Anticipated

♠️ Adequate fluid intake helps keep stools soft and easier to pass, reducing the risk of constipation.

♠️ Constipation can lead to straining, which can cause small tears or trauma in the rectal mucosa.

♠️ Any break in the mucosal barrier can create a potential entry point for bacteria in a client whose immune defenses are already compromised.

♠️ Neutropenic clients are particularly vulnerable to infection from organisms that normally live in the gastrointestinal tract.

♠️ Increasing fluids, when not contraindicated by cardiac or renal disease, supports normal bowel function.

♠️ The nurse may also encourage appropriate dietary fiber and activity when these measures are safe and allowed.

♠️ Rectal procedures such as enemas, rectal suppositories, and rectal temperatures are generally avoided because they can injure the mucosa.

♠️ Therefore, preventing constipation is part of protecting the client from mucosal injury and subsequent infection.

✅ Educate the client to avoid the use of tampons during their period — Anticipated

♠️ Tampons are inserted into the vaginal canal and may cause minor mucosal irritation or microscopic trauma during insertion or removal.

♠️ In a neutropenic client, even small mucosal injuries can increase the risk of local or systemic infection.

♠️ The vaginal area naturally contains microorganisms that normally do not cause illness in an immunocompetent person.

♠️ With neutropenia, the body has a reduced ability to contain these organisms if they cross damaged mucosal barriers.

♠️ Prolonged tampon use can also increase moisture and bacterial growth in the vaginal area.

♠️ Sanitary pads are generally preferred because they do not require insertion into the vagina.

♠️ The client should also be taught careful perineal hygiene and frequent changing of pads during menstruation.

♠️ Therefore, avoiding tampons helps reduce mucosal trauma and infection risk in the neutropenic client.

❌ Show the client how to use an electric razor for shaving — Not Anticipated

Using an electric razor is most strongly associated with precautions for clients who have thrombocytopenia or another bleeding risk, because it decreases the chance of cuts and bleeding.

Although avoiding skin injury is still sensible in neutropenia, the electric-razor recommendation is not a primary or defining intervention for neutropenic precautions unless the client also has low platelets or increased bleeding risk.

❌ Do not allow any visitors to enter the client's room — Not Anticipated

Complete restriction of all visitors is generally unnecessary because healthy visitors can usually enter if they follow strict hand hygiene and infection-control measures.

However, visitors who have fever, cough, respiratory illness, recent communicable disease exposure, or other signs of infection should not visit a neutropenic client.

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Answer 10

Correct Answers:

Peripheral edema

Rationale :

🖊️ Peripheral edema in a client with COPD can indicate the development of cor pulmonale (right-sided heart failure), a serious complication of advanced COPD.

🖊️ Chronic COPD can cause persistent hypoxemia, which produces pulmonary vasoconstriction and increases resistance within the pulmonary circulation.

🖊️ Over time, increased pulmonary vascular resistance can lead to pulmonary hypertension, forcing the right ventricle to pump against greater pressure.

🖊️ Continued strain can cause right ventricular hypertrophy and eventual right-sided heart failure, known as cor pulmonale when caused by pulmonary disease.

🖊️ Right-sided heart failure causes systemic venous congestion, allowing fluid to accumulate in dependent tissues and producing peripheral edema, especially in the ankles and lower legs.

🖊️ Other findings of cor pulmonale can include jugular venous distention (JVD), hepatomegaly, weight gain, and dependent edema.

🖊️ The development of peripheral edema therefore represents more than the chronic pulmonary manifestations of COPD; it suggests cardiovascular involvement and disease progression.

🖊️ The nurse should recognize new or worsening peripheral edema as a potentially serious finding requiring further assessment for pulmonary hypertension and right-sided heart failure.

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Potential Actions	Anticipated	not anticipated
Encourage the client to perform personal hygiene care daily.
Place the client in a negative air pressure room.
Teach the client to increase their fluid intake to prevent constipation.
Educate the client to avoid the use of tampons during their period.
Show the client how to use an electric razor for shaving.
Do not allow any visitors to enter the client's room.

W4 NR324 NR329 Exam 1

No.

1 :
A nurse receives report on four clients. Which client should the nurse assess first?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding should the nurse identify as most concerning?

3 :
The nurse is caring for a client with the arterial blood gas results below. What additional finding should the nurse anticipate based on the ABG results?
pH: 7.29
PaCO2: 30 mm Hg
HCO3: 20 mEq/L
Pa02: 94 mm Hg

4 :
A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

5 :
The nurse cares for a client with respiratory acidosis. Which finding is most concerning to the nurse?

6 :
What manifestation should the nurse expect to assess in an older adult client with pneumonia?

7 :
A client with a history of asthma presents to the emergency department with wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. What action(s) should the nurse implement? Select all that apply.

✅ Assist the client into an upright position

✅ Place the client on oxygen via nasal cannula

✅ Administer an albuterol nebulizer as ordered

8 :
What type of immunity does a person gain when they are sick with the measles?

9 :
The nurse plans care for a client admitted with neutropenia.

Correct Answers

10 :
The nurse cares for a client with chronic obstructive pulmonary disease (COPD). What finding should the nurse recognize as an indication that the client has developed a serious complication of this disease?

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W4 NR324 NR329 Exam 1

No.

1 : A nurse receives report on four clients. Which client should the nurse assess first?

2 : The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding should the nurse identify as most concerning?

3 : The nurse is caring for a client with the arterial blood gas results below. What additional finding should the nurse anticipate based on the ABG results?pH: 7.29PaCO2: 30 mm HgHCO3: 20 mEq/LPa02: 94 mm Hg

4 : A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

5 : The nurse cares for a client with respiratory acidosis. Which finding is most concerning to the nurse?

6 : What manifestation should the nurse expect to assess in an older adult client with pneumonia?

7 : A client with a history of asthma presents to the emergency department with wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. What action(s) should the nurse implement? Select all that apply.

✅ Assist the client into an upright position

✅ Place the client on oxygen via nasal cannula

✅ Administer an albuterol nebulizer as ordered

8 : What type of immunity does a person gain when they are sick with the measles?

9 : The nurse plans care for a client admitted with neutropenia.

Correct Answers

10 : The nurse cares for a client with chronic obstructive pulmonary disease (COPD). What finding should the nurse recognize as an indication that the client has developed a serious complication of this disease?

1 :
A nurse receives report on four clients. Which client should the nurse assess first?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding should the nurse identify as most concerning?

3 :
The nurse is caring for a client with the arterial blood gas results below. What additional finding should the nurse anticipate based on the ABG results?
pH: 7.29
PaCO2: 30 mm Hg
HCO3: 20 mEq/L
Pa02: 94 mm Hg

4 :
A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

5 :
The nurse cares for a client with respiratory acidosis. Which finding is most concerning to the nurse?

6 :
What manifestation should the nurse expect to assess in an older adult client with pneumonia?

7 :
A client with a history of asthma presents to the emergency department with wheezing, intercostal retractions, and an oxygen saturation of 88% on room air. What action(s) should the nurse implement? Select all that apply.

8 :
What type of immunity does a person gain when they are sick with the measles?

9 :
The nurse plans care for a client admitted with neutropenia.

10 :
The nurse cares for a client with chronic obstructive pulmonary disease (COPD). What finding should the nurse recognize as an indication that the client has developed a serious complication of this disease?