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A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using tiotropium prevents oral candidiasis, a common side effect of inhaled anticholinergics.
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A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
- A. Refuses to look at the dressing
- B. Requires help with sponge bathing
- C. Asks that the nurse limit visitors to only family
- D. Dresses in a loose nightgown the client brought from home
Correct Answer: A
Rationale: The client demonstrates the most difficult adjustment to the loss if she refuses to look at the dressing. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery. Requiring help with sponge bathing is expected after major surgery, limiting visitors is also an expected behavior soon after surgery, and dressing in her own nightgown indicates that the client is retaining her self-esteem.
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
- A. The client has refrigerated foods labelled with an expiration date.
- B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
- C. The client uses the FIFO method for insuring food safety.
- D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Correct Answer: B
Rationale: The absence of scatter rugs is a safety feature, not a concern requiring education. Labeled foods , FIFO method , and annual smoke alarm battery replacement are all safe practices. However, the question implies a need for education, and B is the least directly related to a safety deficit, but no clear safety issue is present in the options provided.
A mother calls the clinic after her 4-year-old choked on a peanut. The mother reports that she performed abdominal thrusts and the child is breathing normally now. The nurse should tell the mother to:
- A. Bring the child to the emergency department to check for airway obstruction.
- B. Test the child's urine for blood from internal bleeding.
- C. Call the physician if the child begins to sweat and feels dizzy.
- D. Observe the child for difficulty breathing because the abdominal thrusts may have caused a pneumothorax.
Correct Answer: C
Rationale: After choking, monitoring for symptoms like sweating or dizziness is crucial, as they may indicate complications like aspiration or trauma requiring medical attention.
You are caring for a high risk pregnant client who is in a life threatening situation. The fetus is also at high risk for death. Clinical decisions are being made that concern you because some of these treatments and life saving measures promote the pregnant woman's life at the same time that they significantly jeopardize the fetus' life and viability and other decisions can preserve the fetus's life at the expense of the pregnant woman's life. Which role of the nurse is the priority at this time?
- A. Case manager
- B. Collaborator
- C. Coordinator of care
- D. Advocacy
Correct Answer: D
Rationale: In this complex ethical situation, the nurse's priority role is advocacy . Advocacy involves ensuring that the client's rights, values, and preferences are respected, especially in life-threatening situations with conflicting clinical decisions. The nurse must advocate for informed decision-making, ensuring the client understands the risks and benefits to both herself and the fetus, and support her autonomy in decision-making.
A client with schizophrenia is prescribed risperidone (Risperdal). The nurse should teach the client to report which side effect immediately?
- A. Weight gain
- B. Dry mouth
- C. Tremors
- D. Insomnia
Correct Answer: C
Rationale: Tremors may indicate extrapyramidal side effects, such as parkinsonism, which require prompt reporting to adjust the dose or add an antiparkinsonian medication.