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A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?
- A. Blow as hard as possible into the mouthpiece.
- B. Exhale quickly and forcefully after taking a deep breath.
- C. Inhale as deeply as possible and then blow into the mouthpiece.
- D. Take a deep breath and hold it for 5 seconds before exhaling.
Correct Answer: B
Rationale: The correct answer is B because the client should exhale quickly and forcefully into the peak flow meter after taking a deep breath to measure peak expiratory flow. Choice A is incorrect as blowing as hard as possible may not provide an accurate reading. Choice C is incorrect because inhaling deeply before blowing can affect the results. Choice D is incorrect as holding the breath before exhaling is not part of using a peak flow meter.
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What is the best nursing intervention for a patient experiencing fluid overload?
- A. Administer diuretics
- B. Administer IV fluids
- C. Provide oral fluids
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: The best nursing intervention for a patient experiencing fluid overload is to administer diuretics. Diuretics help the body to remove excess fluid by increasing urine output. This intervention is crucial in managing fluid overload. Administering IV fluids (Choice B) would worsen the condition by adding more fluids to the already overloaded system. Providing oral fluids (Choice C) is not appropriate as it would further contribute to the fluid overload. Chest physiotherapy (Choice D) is not indicated in the treatment of fluid overload and would not address the underlying issue of excess fluid accumulation.
Which medication is used to manage hyperthyroidism?
- A. Levothyroxine
- B. Methimazole
- C. Propylthiouracil
- D. Prednisone
Correct Answer: B
Rationale: Methimazole is the correct answer. It is commonly used to manage hyperthyroidism by inhibiting the production of thyroid hormones. Levothyroxine (Choice A) is actually a medication used to treat hypothyroidism by supplementing thyroid hormones. Propylthiouracil (Choice C) is another anti-thyroid medication used in the management of hyperthyroidism. Prednisone (Choice D) is a corticosteroid and is not typically used in the treatment of hyperthyroidism.
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?
- A. Auscultate the apical pulse and count for 1 minute
- B. Place a sensor on the index finger
- C. Heat the skin prior to placing the probe
- D. Recheck after 10 minutes
Correct Answer: A
Rationale: Corrected Rationale: Auscultating the apical pulse and counting for one minute is the appropriate method to accurately measure a newborn's heart rate. The apical pulse is located at the point of maximum impulse (PMI), which is usually at the fourth or fifth intercostal space along the mid-clavicular line. This method allows for a precise assessment of the newborn's heart rate. Choice B, placing a sensor on the index finger, is incorrect because this method is more suitable for measuring oxygen saturation rather than heart rate. Choice C, heating the skin prior to placing the probe, is unnecessary for assessing heart rate and may lead to potential burns in newborns. Choice D, rechecking after 10 minutes, is not appropriate as immediate assessment and intervention may be required if an abnormal heart rate is detected in a newborn.
What is the priority intervention for a patient with dehydration?
- A. Administer IV fluids
- B. Monitor intake and output
- C. Administer oral fluids
- D. Provide electrolyte replacement
Correct Answer: A
Rationale: The correct answer is to administer IV fluids. This intervention is the priority as it helps rapidly restore hydration in patients with dehydration by delivering fluids directly into the bloodstream. Monitoring intake and output (choice B) is important but comes after providing immediate fluid resuscitation. Administering oral fluids (choice C) may not be sufficient for a patient with dehydration who requires rapid rehydration. Providing electrolyte replacement (choice D) is essential but often follows fluid resuscitation to correct any electrolyte imbalances resulting from dehydration.
A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?
- A. Limit the client's sodium intake to 4 grams per day.
- B. Measure the client's abdominal girth daily.
- C. Monitor the client's urine specific gravity every 12 hours.
- D. Encourage the client to drink 3 liters of fluid per day.
Correct Answer: B
Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.