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1. A client is being educated by a healthcare provider on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching?
- A. ''This medication can decrease my immune response.''
- B. ''I take this medication to prevent asthma attacks.''
- C. ''I need to take this medication with food.''
- D. ''This medication has a slow onset to treat my symptoms.''
Correct answer: B
Rationale: The correct answer is, 'I take this medication to prevent asthma attacks.' Bronchodilators are commonly used to relieve bronchospasm in conditions such as asthma. This medication helps to dilate the airways, making it easier to breathe and preventing asthma attacks. The other options are incorrect: option A is inaccurate as bronchodilators do not decrease immune responses, option C is incorrect as bronchodilators are typically taken on an empty stomach for better absorption, and option D is false as bronchodilators have a rapid onset to provide quick relief of symptoms.
2. What term is used to describe the process of preparing the bed with a new set of linens?
- A. Bed bath
- B. Bed making
- C. Bed shampoo
- D. Bed lining
Correct answer: B
Rationale: The correct answer is 'Bed making.' Bed making is the term used to describe the process of preparing the bed with a new set of linens. This includes changing the sheets, pillowcases, and adding any additional bedding to make the bed clean, fresh, and comfortable for the next use. 'Bed bath' is typically associated with washing a patient in bed, 'Bed shampoo' is not a common term related to bed preparation, and 'Bed lining' does not accurately describe the process of changing linens on a bed.
3. What is the appropriate needle gauge for intradermal injection?
- A. 20G
- B. 22G
- C. 25G
- D. 26G
Correct answer: D
Rationale: Intradermal injections require a very fine needle to be used to deliver the medication into the dermis layer of the skin. A 26G needle is typically used for intradermal injections as it is thin enough to penetrate the skin's surface and deposit the medication accurately.
4. During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. High platelets
- B. Hypertension
- C. Lower platelets
- D. High temperatures
Correct answer: C
Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.
5. In the emergency department, a nurse is assessing a client involved in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. What action should the nurse take first?
- A. Obtain a chest X-ray.
- B. Prepare for chest tube insertion.
- C. Administer oxygen via high-flow mask.
- D. Initiate IV access.
Correct answer: C
Rationale: In this scenario, the client is presenting with signs of respiratory distress, including absent breath sounds, dyspnea, and a low SaO2 level. The priority action should be to improve oxygenation by administering oxygen via a high-flow mask. This intervention aims to increase the oxygen supply to the client's lungs, helping to address the hypoxemia. Once oxygenation is optimized, further interventions, such as obtaining a chest X-ray, preparing for chest tube insertion, or initiating IV access, can be considered based on the client's condition and healthcare provider's orders.
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