Nokea
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Take the medication with meals.
- C. Avoid using the inhaler during an acute attack.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after ipratropium inhalation prevents oral irritation or infection.
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A client has been diagnosed with multi-infarct (or vascular) dementia (MID). When preparing a teaching plan for the client and family, which of the following should the nurse include?
- A. Strategies to manage memory loss and confusion.
- B. Instructions to limit physical activity to prevent falls.
- C. The need for a low-protein diet to reduce metabolic stress.
- D. The importance of avoiding all medications that affect the brain.
Correct Answer: A
Rationale: Multi-infarct dementia involves memory loss and confusion due to multiple small strokes. Teaching strategies to manage these symptoms, such as memory aids and structured routines, is essential for supporting the client and family.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.
A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?
- A. I will need more frequent prenatal visits.'
- B. I should call if I am leaking fluid or have bleeding or contractions.'
- C. I can have sex again in about 2 weeks.'
- D. I can have nothing in my vagina until I am at term.'
Correct Answer: C
Rationale: Sexual intercourse is typically contraindicated after cerclage until term to prevent complications. The other statements reflect correct understanding of cerclage care.
A female client with paranoid schizophrenia has been hearing negative voices and 'getting special messages from various sources,' which of the following interventions is most appropriate for the client's symptoms?
- A. Asking her to make simple decisions
- B. Being matter-of-fact with her
- C. Monitoring her reactions to television programs
- D. Reinforcing appropriate dress and hygiene
Correct Answer: B
Rationale: Being matter-of-fact helps ground a client with paranoid schizophrenia, reducing misinterpretations of reality. Decision-making, TV monitoring, or hygiene reinforcement are less directly related to auditory hallucinations.
A child's plan of care lists increasing protein intake as a goal. Which of the following foods that the child likes should the nurse encourage the child to eat?
- A. A bacon, lettuce, and tomato sandwich.
- B. Fruit-flavored yogurt.
- C. Nacho chips and salsa.
- D. Crackers with butter and jelly.
Correct Answer: B
Rationale: Fruit-flavored yogurt is a good source of protein, suitable for increasing protein intake in a child's diet.