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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 nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with food.
- B. I will contact my provider if my heart rate is below 60 beats per minute.
- C. I should take an antacid with this medication to prevent gastrointestinal upset.
- D. I will need to take this medication for 14 days.
Correct answer: B
Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.
3. A client is postoperative following hip replacement surgery. Which of the following instructions should the nurse include in preventing dislocation of the prosthesis?
- A. Cross your legs at the knees
- B. Avoid bending your hip more than 90 degrees
- C. Sit with your legs elevated
- D. Avoid placing a pillow under your knees
Correct answer: B
Rationale: To prevent dislocation of the prosthesis after hip replacement surgery, it is essential to avoid bending the hip more than 90 degrees. This precaution helps maintain the stability of the hip joint and reduces the risk of prosthesis dislocation. Crossing legs at the knees (Choice A) can increase pressure on the hip joint, leading to instability. Sitting with legs elevated (Choice C) and avoiding placing a pillow under the knees (Choice D) do not directly address the risk of prosthesis dislocation.
4. What are the key nursing interventions for a patient with a tracheostomy?
- A. Maintain a patent airway and monitor for infection
- B. Suction airway secretions and provide humidified oxygen
- C. Educate patient on self-care and tracheostomy cleaning
- D. Change tracheostomy ties daily
Correct answer: A
Rationale: The correct answer is to maintain a patent airway and monitor for infection. These are crucial nursing interventions for patients with tracheostomies to ensure adequate oxygenation and prevent complications. Suctioning airway secretions and providing humidified oxygen can be part of the care plan but are not as essential as maintaining a patent airway. Educating the patient on self-care and tracheostomy cleaning is important for long-term management but is not as immediate as ensuring a patent airway and monitoring for infection. Changing tracheostomy ties daily is a specific task related to tracheostomy care but is not as critical as ensuring the airway is clear and infection-free.
5. A nurse is reviewing the medical record of a client with dementia. Which of the following findings should the nurse address first?
- A. Psychosocial stressors
- B. Restlessness and agitation
- C. Frequent wandering at night
- D. Urinary incontinence
Correct answer: B
Rationale: In clients with dementia, restlessness and agitation are important symptoms that the nurse should address first. These symptoms can indicate underlying issues such as pain, discomfort, or unmet needs, and addressing them promptly can prevent complications. Psychosocial stressors may contribute to the client's condition but should not be the initial priority. Frequent wandering at night and urinary incontinence are also common in dementia but do not pose immediate risks compared to restlessness and agitation.
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