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A client is experiencing shortness of breath and wheezing. What is the nurse's first action?
- A. Administer bronchodilator medication
- B. Check the client's oxygen saturation
- C. Encourage the client to use pursed-lip breathing
- D. Elevate the head of the bed
Correct Answer: A
Rationale: Administering a bronchodilator is the priority intervention to open the airways and relieve wheezing and shortness of breath. Bronchodilators work quickly to dilate the airways, making it easier for the client to breathe. Checking oxygen saturation is important but can be done after initiating bronchodilator therapy. Encouraging pursed-lip breathing and elevating the head of the bed can help improve breathing patterns but should follow the administration of the bronchodilator.
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A client with hypothyroidism is prescribed levothyroxine. What should the nurse include in the teaching plan about this medication?
- A. Take the medication with a full meal
- B. Take the medication on an empty stomach
- C. Take the medication at bedtime
- D. Take the medication as needed for symptoms
Correct Answer: B
Rationale: The correct answer is B: 'Take the medication on an empty stomach.' Levothyroxine should be taken on an empty stomach to enhance absorption and effectiveness. The medication is typically taken in the morning before breakfast. Choice A is incorrect because taking levothyroxine with a full meal can decrease its absorption. Choice C is incorrect because bedtime dosing may lead to insomnia. Choice D is incorrect because levothyroxine is a daily medication for hypothyroidism, not to be taken as needed for symptoms.
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
- A. Encourage the client to drink more slowly
- B. Stop feeding and assess for signs of aspiration
- C. Elevate the head of the bed further
- D. Teach coughing and deep breathing exercises
Correct Answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?
- A. Evaluate the client's swallowing ability.
- B. Reorient the client frequently.
- C. Patch one eye to minimize confusion.
- D. Perform range of motion exercises.
Correct Answer: A
Rationale: The correct answer is to evaluate the client's swallowing ability. Osmotic demyelination can cause dysphagia, putting the client at risk for aspiration. Assessing swallowing function is crucial to prevent complications such as aspiration pneumonia. Reorienting the client frequently (Choice B) is more suitable for confusion related to conditions like delirium. Patching one eye (Choice C) is a technique used for diplopia or double vision, not specifically indicated for osmotic demyelination. Performing range of motion exercises (Choice D) may be beneficial for preventing complications of immobility but is not the priority intervention for osmotic demyelination.
A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?
- A. Encourage discussion of feelings about the loss of his limb.
- B. Administer a prescription for gabapentin.
- C. Teach the client how to wrap the stump with an elastic bandage.
- D. Offer to assist the client to a quieter location to relax.
Correct Answer: B
Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.
A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?
- A. Baked apples with raisins.
- B. Yogurt with fresh berries.
- C. Avocados and cheese.
- D. Fresh fruit salad.
Correct Answer: B
Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.