Nokea
A client who uses a respiratory inhaler asks the nurse to explain how he can know when half his medication is empty so that he can refill his prescription. The nurse should tell the client to:
- A. Shake the inhaler and listen for the contents.
- B. Drop the inhaler in water to see if it floats.
- C. Check for a hissing sound as the inhaler is used.
- D. Press the inhaler and watch for the mist.
Correct Answer: B
Rationale: Dropping the inhaler in water to see if it floats is a practical way to estimate remaining medication; a half-empty inhaler will float, while a full one sinks.
You may also like to solve these questions
The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds and exposure to people who are ill.
- B. Keep the head of the bed elevated at night.
- C. Wear socks and gloves when going outside.
- D. Recognize clinical manifestations of thrombosis.
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising thrombosis risk. Teaching to recognize thrombosis symptoms (e.g., pain, swelling) is critical. Avoiding crowds (A) is for neutropenia, elevating the bed (B) is for reflux, and socks/gloves (C) are for Raynaud’s.
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves?
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and larynx, contributing to the gag reflex. Absence of the gag reflex suggests vagus nerve injury. Hypoglossal (XII) controls tongue movement, glossopharyngeal (IX) aids taste and swallowing, and facial (VII) controls facial muscles.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
A client with AIDS tells the nurse that he has been using herbal supplements in addition to the regimen of drugs prescribed by the physician. The nurse should tell the client that:
- A. Most herbals are well suited to use with prescription medications.
- B. He should buy only FDA-approved herbal supplements for use.
- C. The use of herbals may alter the effect of the medication he is taking.
- D. The herbal supplements should be taken at the same time as his medication.
Correct Answer: C
Rationale: Herbal supplements can interact with antiretroviral drugs, altering their efficacy or toxicity (e.g., St. John’s wort reduces protease inhibitor levels). The nurse should advise the client to discuss herbals with the physician, as they are not inherently safe or FDA-regulated for this purpose.
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, active phase
- C. Stage 3, transition phase
- D. Stage 1, latent phase
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.