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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 teaching a client who is to undergo total knee arthroplasty about postoperative care. Which of the following instructions should the nurse include?
- A. Apply heat to the affected knee
- B. Avoid placing pillows under the knee
- C. Avoid moving the knee for 2-3 days
- D. Apply ice to the affected knee for 24-48 hours
Correct answer: D
Rationale: The correct answer is to apply ice to the affected knee for 24-48 hours. Applying ice helps to reduce inflammation and pain after knee surgery, promoting healing. Choice A is incorrect because heat is not recommended postoperatively, as it can increase swelling. Choice B is incorrect because pillows should be placed under the knee to keep it elevated. Choice C is incorrect because early mobilization is essential for preventing complications such as blood clots.
3. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?
- A. Offer medical advice
- B. Offer general leads
- C. Ask open-ended questions
- D. Use assertive communication
Correct answer: B
Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.
4. What is the correct procedure for inserting a nasogastric (NG) tube?
- A. Measure the tube and insert with lubrication
- B. Insert with lubrication and no measurement
- C. Insert without lubrication and secure it
- D. Insert with lubrication and check placement
Correct answer: A
Rationale: The correct procedure for inserting a nasogastric (NG) tube involves measuring the tube to ensure the appropriate length for insertion and using lubrication to reduce discomfort and aid in smooth insertion. Choice B is incorrect as measuring the tube is essential for proper placement. Choice C is incorrect as lubrication helps in easing the insertion process. Choice D is incorrect as checking the placement comes after insertion and should not be done simultaneously with the insertion process.
5. While caring for a client with an IV infusion who develops redness and warmth at the IV site, what is the most appropriate intervention?
- A. Elevate the IV site and apply an ice pack
- B. Administer an anti-inflammatory medication
- C. Apply a cold compress to the IV site
- D. Discontinue the IV and notify the provider
Correct answer: D
Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (Choice A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (Choice B) is not the primary intervention for phlebitis. Applying a cold compress (Choice C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.
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