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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. What are the key nursing assessments for a patient receiving enteral feeding?
- A. Monitor gastric residual volume and check for abdominal distension
- B. Ensure the correct placement of the feeding tube
- C. Assess for signs of dehydration and electrolyte imbalances
- D. Elevate the head of the bed to prevent aspiration
Correct answer: A
Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.
3. A nurse is teaching a client who is at risk for developing osteoporosis. Which of the following recommendations should the nurse make?
- A. Walk for at least 30 minutes each day
- B. Avoid sunlight exposure
- C. Take vitamin B12 supplements
- D. Increase calcium intake to 1,500 mg per day
Correct answer: D
Rationale: The correct answer is to increase calcium intake to 1,500 mg per day. Adequate calcium intake is essential for maintaining bone density and reducing the risk of osteoporosis. Walking for at least 30 minutes each day is beneficial for overall health but is not as directly related to osteoporosis prevention as calcium intake. Sunlight exposure is important for vitamin D synthesis, which is necessary for calcium absorption, so avoiding sunlight exposure would not be recommended. Vitamin B12 supplements are not directly related to bone health or osteoporosis prevention, so this would not be the most appropriate recommendation.
4. What is the first step in assessing a patient with suspected stroke?
- A. Check for facial droop
- B. Assess speech clarity
- C. Perform a neurological assessment
- D. Call for emergency assistance
Correct answer: D
Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.
5. What are the risk factors for pressure ulcer development?
- A. Immobility and poor nutrition
- B. Obesity and diabetes
- C. Dehydration and malnutrition
- D. Use of assistive devices and prolonged bedrest
Correct answer: A
Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.
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