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A client is prescribed albuterol (Proventil) via a metered-dose inhaler. Which action should the nurse take to ensure effective use of this medication?
- A. Instruct the client to inhale quickly while administering the medication.
- B. Have the client hold their breath for 10 seconds after inhaling the medication.
- C. Tell the client to exhale immediately after inhaling the medication.
- D. Encourage the client to use the inhaler as needed only when experiencing symptoms.
Correct Answer: B
Rationale: The correct answer is B: Have the client hold their breath for 10 seconds after inhaling the medication. This action promotes medication deposition in the lungs by allowing the albuterol to reach deeper into the airways. Holding the breath for 10 seconds ensures better absorption and effectiveness of the medication.
Explanation of Incorrect Choices:
A: Inhaling quickly may cause the medication to not reach the lower airways effectively.
C: Exhaling immediately after inhaling the medication can decrease the amount of medication reaching the lungs.
D: Using the inhaler only when experiencing symptoms may lead to ineffective management of respiratory conditions.
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A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
A very obese female client returns to her room after abdominal surgery. The client is drowsy, but oriented; her abdominal dressing is dry and intact; and her vital signs are T 98.4, P 87, R 18, and BP 146/72. An appropriate postoperative nursing diagnosis would be:
- A. that airway clearance is ineffective.
- B. noncompliance.
- C. altered nutrition, less than her body requirements.
- D. alteration in comfort, abdominal pain.
Correct Answer: D
Rationale: The assessment information provided does not suggest a postoperative airway problem or a problem with compliance. The assessment information provided does not suggest a problem with compliance or a postoperative airway problem. While the client is obese and has altered nutrition, the nutritional problem is more than her body requirements, not less. Pain is a common phenomenon in clients who have had surgery. Postoperative pain is related to the manipulation of and the injury to tissues during the surgical procedure.
A client diagnosed with a new onset of diabetes requires instruction on how to use a glucometer and self-administer insulin. What information will you need to gather in the learner assessment?
- A. Current knowledge level,preferred learning style and readiness to learn.
- B. Only current knowledge level.
- C. Only preferred learning style.
- D. Only readiness to learn.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is experiencing an acute exacerbation of asthma. Which medication should the nurse administer first?
- A. Albuterol (Proventil)
- B. Ipratropium (Atrovent)
- C. Salmeterol (Serevent)
- D. Fluticasone (Flovent)
Correct Answer: A
Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms.
Summary of other choices:
B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief.
C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations.
D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations
What is your evaluation of the nursing action regarding continuous bubbling in the water-seal chamber?
- A. Incorrect, chest tubes should never be clamped because of the risk of tension pneumothorax
- B. Correct, clamping the chest tubes demonstrated that the system was intact; the leak was in the patient
- C. Partially correct, since clamping the chest tubes corrected the pattern, the nurse should have left them clamped until the physician checked the patient
- D. Partially correct, the nurse should have increased the external suction while waiting for the physician to come
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.