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A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale the medication for 1 second
- B. Shake the inhaler vigorously before use
- C. Hold the inhaler 1-2 inches from the mouth
- D. Exhale immediately after inhalation
Correct Answer: C
Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs. Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate. Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing. Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.
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A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?
- A. I will soak my feet in hot water daily
- B. I will wear my slippers whenever I am out of bed
- C. I should apply lotion between my toes after washing my feet
- D. I will cut my nails in a rounded shape
Correct Answer: B
Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.
A client at risk for pressure injuries is being cared for by a nurse. What intervention should the nurse implement?
- A. Keep the client in one position
- B. Use a special mattress for the client
- C. Turn the client every 4 hours
- D. Provide extra pillows for positioning
Correct Answer: B
Rationale: The correct intervention for a client at risk for pressure injuries is to use a special mattress. Special mattresses help reduce the risk of pressure injuries by redistributing pressure on bony areas, thus preventing tissue damage. Keeping the client in one position (choice A) can actually increase the risk of pressure injuries due to prolonged pressure on specific areas. Turning the client every 4 hours (choice C) is important for preventing pressure injuries, but using a special mattress is a more effective intervention. Providing extra pillows for positioning (choice D) may offer some comfort but does not address the primary intervention of pressure redistribution that a special mattress provides.
A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and swollen. What is the nurse's priority action?
- A. Apply a cold compress
- B. Discontinue the IV line
- C. Elevate the limb
- D. Increase the IV flow rate
Correct Answer: B
Rationale: The correct answer is to discontinue the IV line. The client's symptoms of a burning sensation, redness, and swelling at the IV site indicate phlebitis, which is inflammation of the vein. The priority action in this situation is to remove the source of irritation, which is the IV line, to prevent further complications such as infection or thrombosis. Applying a cold compress may provide temporary relief but does not address the underlying issue. Elevating the limb is not the priority in this case. Increasing the IV flow rate can worsen the phlebitis by causing further irritation to the vein.
A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct Answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.
A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
- A. Canned soup
- B. Fresh fruit
- C. Processed meats
- D. Frozen meals
Correct Answer: B
Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.