Nokea
A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?
- A. After taking this medication, I will rinse my mouth with water.'
- B. At the first sign of an asthma attack, I will take this medication.'
- C. I have been smoking for 12 years, but I just quit a month ago.'
- D. I received the pneumococcal vaccine about a month ago.'
Correct Answer: B
Rationale: Fluticasone/salmeterol is a maintenance medication for asthma, not a rescue inhaler for acute attacks. Statement B indicates a misunderstanding, requiring further teaching to clarify that a short-acting bronchodilator (e.g., albuterol) should be used for acute symptoms. Rinsing the mouth (A) prevents oral thrush from the steroid component. Quitting smoking (C) and receiving a vaccine (D) are positive health behaviors not requiring correction.
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During the evaluation phase for a client, the nurse should focus on
- A. All finding of physical and psychosocial stressors of the client and in the family
- B. The client's status, progress toward goal achievement, and ongoing re-evaluation
- C. Setting short and long-term goals to insure continuity of care from hospital to home
- D. Select interventions that are measurable and achievable within selected timeframes
Correct Answer: B
Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
- A. Aphasia
- B. Apraxia
- C. Dysarthria
- D. Dysphagia
Correct Answer: A
Rationale: Aphasia (A) is a language disorder causing difficulty with word choice or expression, common in stroke affecting language centers. The client’s ability to follow commands but use incorrect words suggests expressive aphasia. Apraxia (B) affects motor planning, dysarthria (C) impairs speech articulation, and dysphagia (D) involves swallowing difficulties, none of which match the described deficit.
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.
The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
- A. Client in a belt restraint in the semi-Fowler position
- B. Client in mitten restraints in the side-lying position
- C. Client in soft wrist restraints in the supine position
- D. Client in vest restraint in the high-Fowler position
Correct Answer: D
Rationale: A vest restraint in the high-Fowler position (D) poses a risk of strangulation or asphyxiation due to the restraint slipping upward, requiring immediate intervention. Belt restraint in semi-Fowler (A), mitten restraints in side-lying (B), and wrist restraints in supine (C) are safer positions, assuming proper application and monitoring.