37. Which oassessment ofinding oin oa opatient owho ohas oreceived oomalizumab o(Xolair) ois omost
oimportant oto oreport oimmediately oto othe ohealth ocare oprovider?
a. Pain oat oinjection osite oc. oPeak oflow oreading o75% oof onormal
b. Flushing oand odizziness od. oRespiratory orate o24
obreaths/minute oANS: oB
Flushing oand odizziness omay oindicate othat othe opatient ois oexperiencing oan oanaphylactic oreaction, oand
oimmediate ointervention ois oneeded. oThe oother oinformation oshould oalso obe oreported, obut odo onot
oindicate opossibly olife- othreatening ocomplications oof oomalizumab otherapy.
38. The onurse oin othe oemergency odepartment oreceives oarterial oblood ogas oresults ofor ofour orecently
oadmitted opatients owith oobstructive opulmonary odisease. oThe oresults ofor owhich opatient owill orequire othe
omost orapid oaction oby othe onurse?
a. pH o7.28, oPaCO2 o50 omm oHg, oand oPaO2 o58 omm oHg
b. pH o7.48, oPaCO2 o30 omm oHg, oand oPaO2 o65 omm oHg
c. pH o7.34, oPaCO2 o33 omm oHg, oand oPaO2 o80 omm oHg
d. pH o7.31, oPaCO2 o58 omm oHg, oand oPaO2 o64
omm oHg oANS: oA
The opH, oPaCO2, oand oPaO2 oindicate othat othe opatient ohas osevere ouncompensated orespiratory oacidosis
oand ohypoxemia. oRapid oaction owill obe orequired oto oprevent oincreasing ohypoxemia oand ocorrect othe
oacidosis.
OBJ: oSpecial oQuestions: oPrioritization o| oSpecial oQuestions: oMultiple oPatients
39. Which onursing oaction ofor oa opatient owith ochronic oobstructive opulmonary odisease o(COPD) ocould
othe onurse odelegate oto oexperienced ounlicensed oassistive opersonnel o(UAP)?
a. Obtain oO2 osaturation ousing opulse ooximetry.
b. Monitor ofor oincreased oO2 oneed owith oexercise.
c. Teach othe opatient oabout osafe ouse oof oO2 oat ohome.
d. Adjust oO2 oto okeep osaturation oin oprescribed
oparameters. oANS: oA
UAP ocan oobtain oO2 osaturation o(after obeing otrained oand oevaluated oin othe oskill). o The oother oactions
orequire omore oeducation oand oa oscope oof opractice othat olicensed opractical/vocational onurses
o(LPN/LVNs) oor oregistered onurses o(RNs) owould ohave.
OBJ: oSpecial oQuestions: oDelegation o40. oThe oclinic onurse omakes oa ofollow-up otelephone ocall oto oa
opatient owith oasthma. oThe opatient oreports ohaving oa obaseline opeak oflow oreading oof o600 oL/min, oand
othe ocurrent opeak oflow ois o420 oL/min. oWhich oaction oshould othe onurse otake ofirst?
a. Tell othe opatient oto ogo oto othe ohospital oemergency odepartment.
b. Instruct othe opatient oto ouse othe oprescribed oalbuterol o(Ventolin oHFA).
c. Ask oabout orecent oexposure oto oany onew oallergens oor oasthma otriggers.
,d. Question othe opatient oabout ouse oof othe oprescribed oinhaled
ocorticosteroids. oANS: oB
The opatient’s opeak oflow ois o70% oof onormal, oindicating oa oneed ofor oimmediate ouse oof oshort-acting ob2-
adrenergic oSABA omedications. oAssessing ofor ocorrect ouse oof omedications oor oexposure oto oallergens ois
oalso oappropriate, obut owould onot oaddress othe ocurrent odecrease oin opeak oflow. oBecause othe opatient ois
ocurrently oin othe oyellow ozone, ohospitalization ois onot oneeded.
OBJ: oSpecial oQuestions: oPrioritization o41. oThe onurse oreviews othe omedication oadministration orecord
o(MAR) ofor oa opatient ohaving oan oacute oasthma oattack. oWhich omedication oshould othe onurse
oadminister ofirst?
a. Methylprednisolone o(Solu-Medrol) o60 omg oIV
b. Albuterol o(Ventolin oHFA) o2.5 omg oper onebulizer
c. Salmeterol o(Serevent) o50 omcg oper odry-powder oinhaler o(DPI)
d. Ipratropium o(Atrovent) o2 opuffs oper ometered-dose oinhaler
o(MDI) oANS: oA
Albuterol ois oa orapidly oacting obronchodilator oand ois othe ofirst-line omedication oto oreverse oairway
onarrowing oin oacute oasthma oattacks. oThe oother omedications owork omore oslowly.
OBJ: oSpecial oQuestions: oPrioritization o42. oThe onurse oreceives oa ochange-of-shift oreport oon othe
ofollowing opatients owith ochronic oobstructive opulmonary odisease o(COPD). oWhich opatient oshould othe
onurse oassess ofirst?
a. oA opatient owith oloud oexpiratory owheezes
b. oA opatient owith oa orespiratory orate oof o38 obreaths/min
c. oA opatient owho ohas oa ocough oproductive oof othick, ogreen omucus
d. oA opatient owith ojugular ovenous odistention oand operipheral
oedema oANS: oB
A orespiratory orate oof o38/min oindicates osevere orespiratory odistress, oand othe opatient oneeds oimmediate
oassessment oand ointervention oto oprevent opossible orespiratory oarrest. oThe oother opatients oalso oneed
oassessment oas osoon oas opossible, obut othey odo onot oneed oto obe oassessed oas ourgently oas othe opatient
owith otachypnea.
OBJ: oSpecial oQuestions: oPrioritization o| oSpecial oQuestions: oMultiple oPatients
43. Which ofinding oin oa opatient ohospitalized owith obronchiectasis ois omost oimportant oto oreport oto othe
ohealth ocare oprovider?
a. Cough oproductive oof obloody, opurulent omucus
b. Scattered ocrackles oand owheezes oheard obilaterally
c. Complaint oof osharp ochest opain owith odeep obreathing
d. Respiratory orate o28 obreaths/minute owhile
oambulating oANS: oA
, Hemoptysis omay oindicate olife-threatening ohemorrhage, oand oshould obe oreported oimmediately
oto othe ohealth ocare oprovider. oThe oother ofindings oare ofrequently onoted oin opatients owith
obronchiectasis oand omay oneed ofurther oassessment obut oare onot oindicators oof olife-threatening
ocomplications.
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