Nokea
A client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply.
- A. Activation of the MDI is not coordinated with inspiration.
- B. The client inspires rapidly when using the MDI.
- C. The client holds his breath for 3 seconds after inhaling with the MDI.
- D. The client shakes the MDI after use.
- E. The client performs puffs in rapid succession.
Correct Answer: A,B,C,E
Rationale: Incorrect MDI use includes not coordinating activation with inspiration (A), rapid inspiration (B), holding breath for only 3 seconds (C; should be 10 seconds), and rapid successive puffs (E; wait 1 minute between puffs). Shaking after use (D) is incorrect but less critical.
You may also like to solve these questions
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. "Has an intention tremor of the right hand."
- B. "Right-hand tremor worsens with purposeful acts."
- C. "Needs assistance with dressing and eating due to severe trembling and clumsiness."
- D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema and ascites. ROM exercises (A) and elevation (D) are supportive but secondary. Abdominal massage (B) is not indicated.
The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia?
- A. Somnolence.
- B. Restlessness.
- C. Chills.
- D. Urgency.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxemia, as the brain responds to low oxygen levels with agitation before more severe symptoms like somnolence or cyanosis appear.