A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is afebrile, heart rate 96 beats/minute, respirations 32 breaths/minute, and pulse oximeter reading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expirations. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

Pneumonia.

Pneumothorax.

Asthma.

Bronchitis.

Answer and Explanation

The Correct Answer is C

A. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.

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Correct Answer is C

Explanation

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.
B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.
C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.
D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

A. Coronary artery bypass procedure was performed in 1995. B. Colonoscopy performed for routine screening six months ago. C. Digoxin and furosemide daily since 1996. D. Suffered with depression following death of spouse in 1999.

Correct Answer is C

Explanation

A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.
B. A recent colonoscopy is not relevant to the client's current symptoms.
C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.
D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

Correct Answer is C

Explanation

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

The nurse is administering the muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention should the nurse implement?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?