NR-324 Adult Health I - Set 2 - Part 2

Correct Answer: Perform emergency needle decompression on the affected side

These findings describe a tension pneumothorax, which is a clinical diagnosis treated at once. Emergency needle decompression relieves the trapped pressure and restores venous return, and a chest tube is placed afterward. Option a is incorrect because treatment must not wait for imaging. Moving a hemodynamically collapsing client to radiology wastes the minutes in which rising intrapleural pressure is shutting down venous return to the heart. Option b is incorrect because blood gas results would confirm what the bedside picture already shows and would change nothing about the first step. Obstructive shock is corrected mechanically, not by laboratory analysis. Option c is incorrect because a chest tube does follow, but only after decompression, and it is placed at the bedside in this emergency. Delaying for transfer to an operating suite would be unsafe.

Correct Answer: Keep vitamin K intake steady each week

Warfarin antagonizes vitamin K, so the goal is consistency rather than avoidance. Eating roughly the same amount of vitamin K containing food each week keeps the international normalized ratio stable. Potassium is unrelated to warfarin. Option a is incorrect because cutting out leafy greens creates the same instability as eating them erratically. A steady intake, not an empty plate, is what allows the dose to be titrated reliably. Option c is incorrect because potassium has no interaction with this anticoagulant. Restricting it addresses a mineral the drug never touches while leaving the real dietary issue, vitamin K consistency, unaddressed. Option d is incorrect because timing a supplement alongside the tablet does not make an unnecessary product safe or useful. Nothing in this regimen calls for extra potassium, and unsupervised supplements should be discussed first.

Correct Answer: Stop the infusion and call for emergency help

Stridor with swelling after a new drug signals impending airway obstruction from anaphylaxis. Stopping the drug removes the trigger and summoning help brings the epinephrine and airway support the client needs within minutes. Option a is incorrect because vital signs will confirm what the nurse can already hear and see, and gathering them delays treatment of an airway that is closing while the nurse works. Option b is incorrect because waiting fifteen minutes allows laryngeal swelling to progress to complete obstruction, and the drug still running is the cause of the reaction the client is having. Option d is incorrect because anything taken by mouth risks aspiration in a client whose upper airway is narrowing, and fluids do nothing to reverse the swelling of laryngeal tissue.

Correct Answer: "Finish the entire course as it was prescribed."

Clients are taught to complete the full course even after feeling better. Typical community-acquired pneumonia therapy runs five to seven days, and stopping early leaves surviving organisms behind and promotes antibiotic resistance. Option a is incorrect because defervescence shows the drug is working, not that the infection is eradicated. Clinical improvement in fever and breathing appears well before the organism has been fully cleared. Option c is incorrect because hoarding antibiotics leads to self-treatment with the wrong drug at the wrong dose. This practice is a recognised driver of resistance and leaves the current infection undertreated. Option d is incorrect because intermittent dosing produces sub-therapeutic blood levels that select resistant organisms. Cough may linger for weeks after the infection clears and is a poor guide to when medication is needed.

Correct Answer: Take a deep breath and hold it during removal

Taking a deep breath and holding it, or bearing down, raises intrathoracic pressure above atmospheric so air cannot be drawn in as the tube leaves. An airtight petrolatum gauze dressing is applied immediately afterward. Option a is incorrect because rapid shallow breathing produces repeated negative pressure swings in the chest. Each inspiration during withdrawal would pull atmospheric air through the tract and risk a recurrent pneumothorax. Option b is incorrect because turning during the pull disturbs the site and the sterile field. Position is arranged beforehand, and the client stays still while the tube is drawn and the dressing sealed. Option c is incorrect because coughing at that instant is uncontrolled and painful, and the pressure it creates is brief rather than sustained. A held breath or a Valsalva maneuver gives steady protection.

Correct Answer: "I will start oxygen now and titrate to target."

A hypoxic client is given oxygen immediately and then titrated down to the target range. Waiting for laboratory results or avoiding oxygen altogether risks death from hypoxia, which develops far faster than retention. Option b is incorrect because a confused cyanotic client cannot wait for a laboratory turnaround. The blood gas guides how far the oxygen comes down afterward; it does not decide whether oxygen is started. Option c is incorrect because the breathing drive explanation is largely a myth and was never a reason to leave a hypoxic client on room air. Titration, not avoidance, is the safe response. Option d is incorrect because maximum flow overshoots the target and, in chronic lung disease, can worsen mismatch and raise carbon dioxide. Oxygen is prescribed to a saturation range rather than to a device setting.

Correct Answer: Positive, because induration reaches five millimetres

For a person with HIV the cut-off is five millimetres or more of induration, because the highest risk group gets the lowest threshold. Six millimetres of induration is therefore a positive result requiring symptom review and a chest film. Option a is incorrect because fifteen millimetres applies to people with no known risk factors. Severe immunosuppression lowers the bar substantially, so using the general threshold would miss infection in the client who most needs finding. Option b is incorrect because only the firm palpable swelling is measured and erythema is disregarded entirely. A wide red ring neither cancels nor diminishes induration that already meets the risk-based cut-off. Option d is incorrect because redness alone, without palpable hardening, is read as a negative test at any width. The conclusion happens to be right here, but it rests on the wrong measurement.

Correct Answer: Notify the provider and prepare for intubation

Normalized carbon dioxide with persistent hypoxemia and drowsiness marks impending ventilatory failure. The nurse stays with the client, escalates at once and states the blood gas trend, because this client needs intensive care and probable mechanical ventilation. Option a is incorrect because documenting and waiting treats a pseudo normal value as recovery. The oxygen level has not risen and the client is drowsy, so an hour of delay could end in respiratory arrest. Option c is incorrect because coaching and reassurance cannot move air through airways that are nearly closed. Drowsiness here reflects rising carbon dioxide and hypoxemia, a physiologic emergency that needs medical escalation rather than breathing coaching. Option d is incorrect because oxygen is never withheld from a hypoxemic client. Hypoxemia kills within minutes while hypercapnia is treatable with ventilation, so oxygen is titrated to a saturation target and the client is monitored closely.

Correct Answer: Trace the tubing for kinks, loops and disconnection

Absent tidaling in a dyspneic client with falling saturation points to obstruction or disconnection until proven otherwise. The nurse traces the tubing from the chest wall to the unit, lifting dependent loops and straightening kinks. Option b is incorrect because re-expansion is the benign explanation only when the client is comfortable, with equal breath sounds and a good saturation. Worsening dyspnea points the other way entirely. Option c is incorrect because removal requires a re-expanded lung, a resolved air leak and minimal drainage. Pulling the tube from a deteriorating client would remove the only route for escaping pleural air. Option d is incorrect because a film takes time to obtain and interpret while a correctable mechanical problem sits at the bedside. Bedside assessment of client and tubing precedes any diagnostic imaging here.

Correct Answer: Return the unit to an upright position immediately

Setting the unit upright at once restores the water seal and separates the chambers again. The nurse then checks the water-seal level, refilling to two centimeters with sterile water, and reassesses the client. Option a is incorrect because a tipped unit calls for a simple physical correction that the nurse performs without delay. Calling the provider first leaves the water seal disrupted while the telephone is answered. Option b is incorrect because clamping is never the response to a tipped unit. Occluding the tube removes the only exit for pleural air and creates a hazard far greater than the spill. Option c is incorrect because replacement becomes necessary only if chamber contents mixed, sterility was lost, or the housing is damaged. Standing the unit up and inspecting it comes before fetching supplies.

Correct Answer: I will take it with food and report any infection.

Oral steroids are taken with food in the morning to limit gastric upset. Because the inflammatory response is blunted, fever may be absent, so any sign of infection is reported promptly during and after the course. Option a is incorrect because a short burst is taken on a fixed daily schedule to settle airway inflammation. Using it only when symptoms flare leaves the swelling and mucus untreated and invites a relapse after discharge. Option c is incorrect because courses of five to seven days need no taper, and clients never adjust a steroid dose on their own. Tapering matters after prolonged therapy, when the adrenal axis has been suppressed. Option d is incorrect because inhaled therapy continues alongside the tablets. The controller keeps working on airway inflammation long after the burst ends, and the rescue inhaler must stay available for sudden symptoms at home.

Correct Answer: Fine crackles from alveoli popping open

Fine crackles are the sudden reopening of small airways and alveoli held collapsed by fluid. That opening mechanism explains both the end inspiratory timing and the failure to clear with a cough. Option a is incorrect because coarse crackles are lower pitched and wetter, heard through both phases of the breath, and they typically change or clear once the client coughs up the secretions. Option b is incorrect because rhonchi are continuous snoring sounds generated in the large central airways, not brief popping at the alveolar level, and a productive cough usually alters them. Option c is incorrect because wheezes are musical and continuous, occur mainly during expiration, and arise when air is forced through airways narrowed by spasm or swelling rather than through reopening alveoli.

Correct Answer: "I will blow into the mouthpiece as hard as I can."

The incentive spirometer is used by inhaling through it, not blowing out. Sustained maximal inspiration is what re-expands collapsed alveoli, so a client who describes blowing into the device needs the technique retaught. Option a is incorrect because sitting upright is correct instruction. Full lung expansion is mechanically impossible lying flat, since the diaphragm cannot descend against abdominal contents, so this statement shows the teaching was understood. Option b is incorrect because holding the breath at full inspiration for three seconds or longer is exactly right. The hold keeps reopened alveoli inflated long enough for surfactant to redistribute across them. Option d is incorrect because splinting the incision with a pillow is encouraged. Support reduces pain during coughing, which lets the client clear the secretions that the deep breaths have loosened.

Correct Answer: Stop the feeding and raise the head

Stopping the feeding removes the source of aspiration and elevating the head uses gravity to protect the airway. Both are immediate nursing actions that require no order and address breathing before diagnostics. Option b is incorrect because auscultation of an injected air bolus is not an accepted method of confirming feeding tube position. It is also a delay while formula continues to enter the lung. Option c is incorrect because imaging will confirm an infiltrate but changes nothing in the next minute. The radiograph is obtained after the feeding is stopped and the client is repositioned and oxygenated. Option d is incorrect because raising the oxygen treats a number while formula keeps pouring into the airway. Continuing an infusion that is actively being aspirated worsens the injury no matter how much oxygen is delivered.

Correct Answer: The tubing is patent and the system is functioning

This movement is tidaling, the normal fluctuation of the water level with the respiratory cycle. It confirms that the tubing is patent and that the system remains in open communication with the pleural space. Option a is incorrect because an air leak shows itself as continuous bubbling through the water, not as a rising and falling column. Tidaling and bubbling are two separate observations in the same chamber. Option b is incorrect because fluctuation reflects the client changing intrapleural pressure rather than the suction setting. Suction adequacy is judged in the third chamber, where gentle bubbling shows the prescribed level is reached. Option c is incorrect because full re-expansion is signaled by the opposite finding, the disappearance of tidaling in a comfortable client with equal breath sounds. Continued fluctuation means the pleural space is still open.

Correct Answer: Sit the client upright and apply oxygen

New restlessness in a client whose saturation is falling is the earliest sign of hypoxia, because the brain tolerates no interruption in supply. Sitting upright and giving oxygen treats the cause immediately. Option a is incorrect because sedating an agitated client masks the one sign that revealed the hypoxia and further depresses breathing. Agitation here is a warning from the brain, not simple discomfort. Option c is incorrect because an hour of waiting allows a client already on the downward part of the curve to deteriorate further. Documentation follows the intervention rather than replacing it. Option d is incorrect because restraints treat the behavior while leaving the oxygen problem untouched, and struggling against them raises oxygen demand in a client who cannot meet current demand.

Correct Answer: Arrange emergency department transport without further delay

Below half of personal best is the red zone, a medical alert. Quick relief medicine is given at once and the provider is called. If the client stays red after fifteen minutes, emergency care follows immediately. Option a is incorrect because every zone is a percentage of the client's own personal best, never of a predicted value for age, height and sex. Substituting predicted numbers misclassifies the severity of this episode. Option b is incorrect because waiting another hour wastes the window in which this deterioration can still be reversed. Breathlessness while speaking is itself a danger sign requiring emergency care regardless of the meter reading. Option d is incorrect because controller medicines produce no acute bronchodilation and cannot rescue an obstructed airway. Observing a red zone client who has already failed quick relief therapy delays the transport that this situation demands.

Correct Answer: Intravenous magnesium sulfate for refractory bronchospasm

Magnesium relaxes bronchial smooth muscle and is given intravenously for severe exacerbation that has not responded to bronchodilators and systemic corticosteroids. Noninvasive ventilation or intubation follows if respiratory failure is established or imminent. Option b is incorrect because the client is already receiving an intravenous corticosteroid, and a slow oral taper addresses nothing happening at this moment. Short exacerbation courses of five to seven days need no taper at all. Option c is incorrect because salmeterol is a maintenance drug whose onset is far too slow for rescue use. Course material prints the rule in capitals that long acting beta agonists are not for acute attacks. Option d is incorrect because a diuretic treats fluid overload, and this client is more likely dehydrated from days of tachypnea and poor intake. Correcting dehydration, not removing volume, is part of status asthmaticus care.

Correct Answer: A computed tomography pulmonary angiogram

Computed tomography pulmonary angiography is the diagnostic study of choice because it shows the clot directly. The nurse first checks for contrast allergy and assesses kidney function, as with any contrast study. Option a is incorrect because the film is usually normal or nearly normal early in embolism. Its value lies in excluding other causes of sudden breathlessness such as pneumothorax or pulmonary edema. Option b is incorrect because that coagulation study monitors unfractionated heparin therapy and diagnoses nothing. It measures the effect of a drug rather than revealing whether a clot is present in the lung. Option d is incorrect because this marker is sensitive but not specific, so it helps rule embolism out when clinical probability is low. Surgery, infection, pregnancy and cancer all raise it.

Correct Answer: Consolidation of the affected lung tissue

Solid, exudate-filled lung conducts sound better than air-filled lung, so central airway sounds are transmitted to the periphery, percussion is dull, and voice sounds change. Together these describe consolidation from pneumonia. Option b is incorrect because air in the pleural space produces hyperresonance with diminished or absent breath sounds on that side. Dullness and loud transmitted sounds are the opposite pattern. Option c is incorrect because narrowed airways generate expiratory wheezing that is usually widespread rather than a single dull, sound-conducting region. Bronchospasm also fails to explain the fever and productive cough. Option d is incorrect because cardiac fluid overload gives bilateral dependent crackles, an extra heart sound and peripheral edema. A localized area of altered voice transmission is not a feature of heart failure.