Solutions
A nurse in the emergency department is caring for a client who
is experiencing an acute asthma attack. Which of the following
findings indicates that the client's respiratory status is declining?
SATA
A.) SpO2 95%
B.) Wheezing
C.) Retraction of sternal muscles
D.) Pink mucous membranes
E.) Tachycardia Correct Answers B.) Wheezing (indicates
narrowing of the airway)
C.) Retraction of sternal muscles (associated with increased
work of breathing)
E.) Tachycardia (caused by decreased oxygenation)
A nurse is assessing a client following a bronchoscopy. Which
of the following findings should the nurse report to the provider?
A.) Blood-tinged sputum
B.) Dry, nonproductive cough
C.) Sore throat
D.) Bronchospasms Correct Answers D.) Bronchospasms
A nurse is assessing a client following a gunshot wound to the
chest. For which of the following findings should the nurse
monitor to detect a pneumothorax? SATA
A.) Tachypnea
, B.) Deviation of the trachea
C.) Bradycardia
D.) Decreased use of accessory muscles
E.) Pleuritic pain Correct Answers A.) Tachypnea
B.) Deviation of trachea
E.) Pleuritic pain
A nurse is assessing a client who has a chest tube and drainage
system in place. Which of the following are expected findings?
SATA
A.) Continuous bubbling in the water seal chamber
B.) Gentle constant bubbling in the suction control chamber
C.) Rise and fall in the level of water in the water seal chamber
with inspiration and expiration
D.) Exposed sutures without dressing
E.) Drainage system upright at chest level Correct Answers B.)
Gentle constant bubbling in the suction control chamber
C.) Rise and fall in the level of water in the water seal chamber
with inspiration and expiration
A nurse is assessing a client who has a history of asthma. Which
of the following factors should the nurse identify y as a risk for
asthma?
A.) Males
B.) Environmental allergies
C.) Alcohol use
D.) History of Diabetes Correct Answers D.) Environmental
allergies