5 The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires the nurse to
intervene?
• A Crying for more than 10 minutes.
• B Acrocyanosis with hands and feet cool to touch.
• C Respiratory rate of 73 breaths/minute.
• D No voiding or stooling since birth.
• C Respiratory rate of 73 breaths/minute.
→ infant is hyperventilating; should be 30-60 breaths/min
An adolescent client was admitted to the unit two days ago for depression. When the mental health nurse tries
to interview the client to establish rapport, the client becomes very irritated and sarcastic. Which action is best
for the nurse to take?
A Plan to talk with the client the next day.
B Offer to play a game of cards with the client. This is to build rapport with the client.
C Report the behavior to the next shift.
D Document the behavior in the chart.
B Offer to play a game of cards with the client. This is to build rapport with the client.
,An adult client comes to the urgent care clinic 5 days after being diagnosed with influenza. The client is short
of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first?
A Auscultate bilateral lung sounds.
B Obtain a sputum sample for culture???. ←
C Check the client's oxygen saturation level.
D Administer an oral antipyretic.
B Obtain a sputum sample for culture
An adult client complains of insomnia and asks the nurse to recommend a sleeping pill. Which reply is best for
the nurse to provide?
A "Sleeping medications have side effects that require caution."
B "Have you discussed this with your healthcare provider?"
C "Zolpidem tartrate is used for insomnia."
D "Tell me about your insomnia and how you treat it."
D "Tell me about your insomnia and how you treat it."
,After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral
antacids without relief.
Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and
blood pressure 116/70 mm Hg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding
is most critical?
• A Irregular pulse rate.
• B Complaint of radiating jaw pain.
• C ST elevation in three leads.
• D Bile colored emesis.
• C ST elevation in three leads.
The antitubular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness
of this medication, which outcome can the nurse expect this client to exhibit?
A Decreased appetite and weight loss.
B A positive sputum smear and culture.
C Decreased cough and sputum.
D Vertigo and tinnitus.
C Decreased cough and sputum.
, Cheyne-Stokes respiration
Abnormal rhythm of breathing (periodic breathing) that alternates b/w hyperventilation & apnea
Cholinergic Crisis - S/s
**BB SLUDGE**
Constricted & Wet
B - Bronchoconstriction
B - Bronchorrhea (massive sputum)
S - Salivation
L - Lacrimation
U - Urine (excessive)
D - Diaphoresis
G - GI upset
E - Emesis
intervene?
• A Crying for more than 10 minutes.
• B Acrocyanosis with hands and feet cool to touch.
• C Respiratory rate of 73 breaths/minute.
• D No voiding or stooling since birth.
• C Respiratory rate of 73 breaths/minute.
→ infant is hyperventilating; should be 30-60 breaths/min
An adolescent client was admitted to the unit two days ago for depression. When the mental health nurse tries
to interview the client to establish rapport, the client becomes very irritated and sarcastic. Which action is best
for the nurse to take?
A Plan to talk with the client the next day.
B Offer to play a game of cards with the client. This is to build rapport with the client.
C Report the behavior to the next shift.
D Document the behavior in the chart.
B Offer to play a game of cards with the client. This is to build rapport with the client.
,An adult client comes to the urgent care clinic 5 days after being diagnosed with influenza. The client is short
of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first?
A Auscultate bilateral lung sounds.
B Obtain a sputum sample for culture???. ←
C Check the client's oxygen saturation level.
D Administer an oral antipyretic.
B Obtain a sputum sample for culture
An adult client complains of insomnia and asks the nurse to recommend a sleeping pill. Which reply is best for
the nurse to provide?
A "Sleeping medications have side effects that require caution."
B "Have you discussed this with your healthcare provider?"
C "Zolpidem tartrate is used for insomnia."
D "Tell me about your insomnia and how you treat it."
D "Tell me about your insomnia and how you treat it."
,After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral
antacids without relief.
Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and
blood pressure 116/70 mm Hg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding
is most critical?
• A Irregular pulse rate.
• B Complaint of radiating jaw pain.
• C ST elevation in three leads.
• D Bile colored emesis.
• C ST elevation in three leads.
The antitubular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness
of this medication, which outcome can the nurse expect this client to exhibit?
A Decreased appetite and weight loss.
B A positive sputum smear and culture.
C Decreased cough and sputum.
D Vertigo and tinnitus.
C Decreased cough and sputum.
, Cheyne-Stokes respiration
Abnormal rhythm of breathing (periodic breathing) that alternates b/w hyperventilation & apnea
Cholinergic Crisis - S/s
**BB SLUDGE**
Constricted & Wet
B - Bronchoconstriction
B - Bronchorrhea (massive sputum)
S - Salivation
L - Lacrimation
U - Urine (excessive)
D - Diaphoresis
G - GI upset
E - Emesis
