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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 type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?
- A. You should not gain more than 10 lbs
- B. Your weight gain should be the same as for someone without diabetes
- C. Avoid gaining more than 15 lbs
- D. You should gain more weight because of your condition
Correct answer: B
Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.
3. What is the primary intervention for a patient with a pneumothorax?
- A. Insert a chest tube
- B. Administer oxygen
- C. Monitor respiratory rate
- D. Administer analgesics
Correct answer: A
Rationale: The correct answer is to insert a chest tube. This intervention is considered the definitive treatment for a pneumothorax as it helps remove air or fluid from the pleural space, re-expanding the lung. Administering oxygen (Choice B) can be supportive but is not the primary intervention to treat a pneumothorax. Monitoring respiratory rate (Choice C) is important but does not address the underlying issue of air in the pleural space. Administering analgesics (Choice D) may help manage pain but does not treat the pneumothorax itself.
4. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?
- A. The client's urination habits.
- B. The client's financial information.
- C. The client's social history.
- D. The client's current level of mobility.
Correct answer: D
Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.
5. A client is expressing concern about extreme fatigue following an acute myocardial infarction. What is the best strategy to promote independence?
- A. Instruct the client to rest until fully recovered
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to complete self-care tasks
- D. Ask the client's family to assist with self-care
Correct answer: B
Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence. This approach helps the client regain confidence and autonomy in performing self-care activities. Instructing the client to rest until fully recovered (Choice A) may lead to decreased muscle strength and independence. Assigning assistive personnel (Choice C) does not empower the client to actively participate in their care. Involving the client's family (Choice D) may provide support but does not directly encourage the client's independence.
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