Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?
A. Inability to exhale retained carbon dioxide
An acute asthma attack is a sudden worsening of asthma symptoms, such as coughing, wheezing, tightness in the chest, and difficulty breathing. These symptoms happen because the airways in the lungs become narrow, irritated, swollen, and produce excess mucus. An asthma attack can be triggered by various factors, such as allergic reactions, respiratory infections, tobacco smoke, cold air, and exercise. These triggers cause the immune system to react and release chemicals that cause inflammation and constriction of the airways. Based on this information, the best answer to the question is a. Inability to exhale retained carbon dioxide. This is because during an asthma attack, the narrowed airways make it harder to exhale the air from the lungs, which leads to a buildup of carbon dioxide in the blood. This can worsen the symptoms and cause acidosis, a condition where the blood becomes too acidic.
B. Acute loss of alveolar elasticity
Acute loss of alveolar elasticity is not a cause of asthma attacks, but a consequence of chronic obstructive pulmonary disease (COPD), a different lung condition that involves damage to the alveoli, the tiny air sacs in the lungs.
C. Decreased responsiveness of airways to allergens
Decreased responsiveness of airways to allergens is not a cause of asthma attacks, but a goal of asthma treatment. Asthma medications aim to reduce the sensitivity and inflammation of the airways to prevent or reduce the frequency and severity of asthma attacks.
D. Suppressed bronchiolar inflammatory response
Suppressed bronchiolar inflammatory response is not a cause of asthma attacks, but a potential side effect of some asthma medications, such as corticosteroids. These drugs can suppress the immune system and increase the risk of infections in the airways.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
An acute asthma attack is a sudden worsening of asthma symptoms, such as coughing, wheezing, tightness in the chest, and difficulty breathing. These symptoms happen because the airways in the lungs become narrow, irritated, swollen, and produce excess mucus.
An asthma attack can be triggered by various factors, such as allergic reactions, respiratory infections, tobacco smoke, cold air, and exercise. These triggers cause the immune system to react and release chemicals that cause inflammation and constriction of the airways.
Based on this information, the best answer to the question is a. Inability to exhale retained carbon dioxide. This is because during an asthma attack, the narrowed airways make it harder to exhale the air from the lungs, which leads to a buildup of carbon dioxide in the blood. This can worsen the symptoms and cause acidosis, a condition where the blood becomes too acidic.
The other options are not correct because:
b. Acute loss of alveolar elasticity is not a cause of asthma attacks, but a consequence of chronic obstructive pulmonary disease (COPD), a different lung condition that involves damage to the alveoli, the tiny air sacs in the lungs.
c. Decreased responsiveness of airways to allergens is not a cause of asthma attacks, but a goal of asthma treatment. Asthma medications aim to reduce the sensitivity and inflammation of the airways to prevent or reduce the frequency and severity of asthma attacks.
d. Suppressed bronchiolar inflammatory response is not a cause of asthma attacks, but a potential side effect of some asthma medications, such as corticosteroids. These drugs can suppress the immune system and increase the risk of infections in the airways.
Similar Questions
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?
A. Increase the client's fluid intake.
B. Check the client's urine output.
Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.
C. Reposition the client in bed.
D. Administer PRN pain medication.
Full Explanation
Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.
A nurse is assessing a client who has a serum sodium level of 120 mEq/L. Which of the following findings should the nurse expect?
A. Decreased bowel sounds
B. Increased central venous pressure
C. Confusion
A serum sodium level of 120 mEq/L indicates hyponatremia, which is a condition where there is an excess of water relative to sodium in the body fluids. Hyponatremia can cause various neurological symptoms such as confusion, lethargy, seizures, coma, and death.
D. Hyperreflexia
Full Explanation
A serum sodium level of 120 mEq/L indicates hyponatremia, which is a condition where there is an excess of water relative to sodium in the body fluids. Hyponatremia can cause various neurological symptoms such as confusion, lethargy, seizures, coma, and death.
A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside?
A. Protamine sulfate
Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.
B. Acetylcysteine
C. Vitamin K
D. Flumazenil
Full Explanation
Protamine sulfate is an antidote for heparin overdose and can reverse its anticoagulant effects. It should be available at the bedside in case of bleeding complications or heparin toxicity. The nurse should monitor the client's activated partial thromboplastin time (aPTT) and adjust the heparin infusion rate accordingly.