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1. 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.
2. A client with hypertension is receiving lifestyle education from a nurse. What should be emphasized?
- A. Encourage a low-sodium diet
- B. Advise the client to avoid caffeinated drinks
- C. Recommend increasing high-protein foods
- D. Advise the client to reduce fat intake
Correct answer: B
Rationale: The correct answer is to advise the client to avoid caffeinated drinks. Caffeine can temporarily increase blood pressure, so avoiding caffeinated drinks can help manage hypertension. Encouraging a low-sodium diet (Choice A) is essential for hypertension management as excess sodium can raise blood pressure. Increasing high-protein foods (Choice C) is not a primary focus in managing hypertension. While reducing fat intake (Choice D) can be beneficial for overall health, it is not the priority in lifestyle modifications for hypertension.
3. A nurse is reviewing the medical record of a client with dementia who frequently becomes agitated. What should the nurse prioritize?
- A. Investigate the client's fluid and electrolyte balance
- B. Investigate the client's recent medication changes
- C. Investigate recent changes in cognitive functioning
- D. Investigate the client's psychosocial environment
Correct answer: B
Rationale: The correct answer is to investigate the client's recent medication changes. In a client with dementia who frequently becomes agitated, medication changes can often be a significant factor contributing to their behavior. Checking recent medication changes can help identify if any specific medication is causing or exacerbating the agitation. Choice A about fluid and electrolyte balance is less likely to be the priority unless there are specific indications in the medical record. Choice C, investigating recent changes in cognitive functioning, may be important but addressing the agitation first is a more immediate concern. Choice D, investigating the client's psychosocial environment, is also important but may not directly address the immediate cause of the agitation as medication changes could.
4. What are the steps in managing a patient with a pressure ulcer?
- A. Clean the wound and apply a hydrocolloid dressing
- B. Debride necrotic tissue and apply antibiotics
- C. Apply an alginate dressing and elevate the affected area
- D. Use moisture-retentive dressings and reposition frequently
Correct answer: A
Rationale: The correct answer is A: Clean the wound and apply a hydrocolloid dressing. This step is crucial in managing a pressure ulcer as it helps protect the ulcer from infection and promotes healing by creating a moist environment conducive to tissue repair. Choice B, debriding necrotic tissue and applying antibiotics, is more suitable for managing infected pressure ulcers but not as the initial step. Choice C, applying an alginate dressing and elevating the affected area, may be part of the management but is not the initial step. Choice D, using moisture-retentive dressings and repositioning frequently, is important for prevention but not the first step in managing an existing pressure ulcer.
5. A nurse in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?
- A. Normal saline
- B. Hydrogen peroxide
- C. Iodine
- D. Alcohol
Correct answer: B
Rationale: The correct answer is B: Hydrogen peroxide. Hydrogen peroxide is commonly used to clean tracheostomy cannulas to prevent infection. Normal saline (choice A) is used for wound irrigation but not for cleaning inner cannulas of tracheostomy tubes. Iodine (choice C) and alcohol (choice D) are not recommended for cleaning tracheostomy cannulas as they can be too harsh and irritating to the delicate tissues of the airway.
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