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1. A healthcare provider is caring for a client with a pressure ulcer and needs to review the client's medical history. Which of the following findings is expected?
- A. A Braden scale score of 20
- B. An albumin level of 3 g/dL
- C. A hemoglobin level of 13 g/dL
- D. A Norton scale score of 18
Correct answer: B
Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.
2. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?
- A. Perform the test in the morning after taking medications
- B. Blow into the meter as slowly as possible
- C. Perform the test when feeling short of breath
- D. Use the peak flow meter after using your rescue inhaler
Correct answer: D
Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.
3. What is the first priority for a patient in respiratory distress?
- A. Administer oxygen
- B. Assess airway patency
- C. Monitor oxygen saturation
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, the primary concern is ensuring an adequate oxygen supply to the body. By administering oxygen, you can help improve oxygenation, which is crucial for the patient's overall well-being. Assessing airway patency is important but administering oxygen takes precedence as it directly addresses the oxygenation concern. Monitoring oxygen saturation is also essential, but the immediate action should be to provide oxygen. Calling for assistance can be important but is not the first priority when dealing with a patient in respiratory distress.
4. What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.
5. A client is being taught about prescribed asthma medications. Which of the following medications should the client use for treatment of an acute asthma attack?
- A. Beclomethasone
- B. Salmeterol
- C. Albuterol
- D. Montelukast
Correct answer: C
Rationale: Albuterol is the correct choice for treating acute asthma attacks because it is a short-acting bronchodilator that provides quick relief by relaxing the muscles in the airways. Beclomethasone (choice A) and Salmeterol (choice B) are long-acting medications used for controlling and preventing asthma symptoms but are not for immediate relief during an acute attack. Montelukast (choice D) is a leukotriene receptor antagonist used for asthma maintenance therapy and not for acute asthma attacks.
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