Nokea
The client is receiving discharge teaching for a new diagnosis of asthma. Which statement by the client indicates a need for further teaching?
- A. I should use my inhaler as soon as I begin to feel short of breath.
- B. I should avoid using my inhaler unless I am having an asthma attack.
- C. I should use my inhaler 30 minutes before exercise.
- D. I should rinse my mouth after using my inhaler.
Correct Answer: B
Rationale: The statement 'I should avoid using my inhaler unless I am having an asthma attack' (B) indicates a need for further teaching. It is important for clients to use their inhaler as prescribed, which may include regular use to prevent asthma attacks. Choice A is correct because using the inhaler when feeling short of breath can help manage asthma symptoms. Choice C is also correct as using the inhaler before exercise can prevent exercise-induced symptoms. Choice D is correct as rinsing the mouth after using the inhaler helps prevent oral thrush, a potential side effect of inhaled corticosteroids. Therefore, option B is the most concerning statement that needs clarification.
You may also like to solve these questions
During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?
- A. Stop advancing the tube and allow the client to rest
- B. Remove the tube and try again after a few minutes
- C. Continue inserting the tube while the client sips water
- D. Withdraw the tube slightly and pause before continuing
Correct Answer: D
Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.
A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?
- A. Administer regular insulin IV.
- B. Administer IV fluids at 250 ml/hr.
- C. Administer sodium bicarbonate IV push.
- D. Administer furosemide (Lasix) IV push.
Correct Answer: A
Rationale: Administering regular insulin IV (A) is the initial intervention for a client with diabetic ketoacidosis (DKA) to rapidly reduce blood glucose levels. This is vital in reversing the ketosis and acidosis seen in DKA. Administering IV fluids (B) helps to correct dehydration and electrolyte imbalances. Administering sodium bicarbonate (C) and furosemide (D) may be necessary depending on the client's condition, but insulin administration takes precedence in the management of DKA.
When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?
- A. Self-care deficit
- B. Functional incontinence
- C. Fluid volume deficit
- D. High risk for infection
Correct Answer: D
Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections.
Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.
The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?
- A. Check for a blood return.
- B. Reposition the client's arm.
- C. Remove the IV site dressing.
- D. Flush the lock with saline.
Correct Answer: B
Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.
Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client's plan of care?
- A. Recent serum hemoglobin level of 16 g/dL
- B. Opioid analgesic received one hour ago
- C. Stooped posture with an unsteady gait
- D. Expressed feelings of depression
Correct Answer: B
Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client's care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.