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A nurse is caring for a patient with a history of asthma. The nurse should educate the patient to avoid which of the following triggers?
- A. Exercise-induced asthma.
- B. Cold, dry air.
- C. Caffeine.
- D. Environmental allergens.
Correct Answer: B
Rationale: The correct answer is B: Cold, dry air. Cold, dry air is a common trigger for asthma exacerbations, as it can irritate the airways and lead to bronchoconstriction. This trigger can worsen asthma symptoms and increase the risk of an asthma attack. Educating the patient to avoid cold, dry air can help prevent asthma flare-ups.
Explanation for why the other choices are incorrect:
A: Exercise-induced asthma is triggered by physical activity but can be managed with proper warm-up and medication. It is not typically something to avoid altogether.
C: Caffeine is a mild bronchodilator and can actually help alleviate asthma symptoms in some cases.
D: Environmental allergens can trigger asthma in some individuals, but they vary from person to person, so avoidance strategies would depend on specific allergens identified through testing.
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When a nurse is assessing a patient's pain level, which of the following questions would be most appropriate?
- A. "How would you rate your pain on a scale from 0 to 10?"
- B. "When did your pain start?"
- C. "What causes your pain?"
- D. "Do you need any medication for the pain?"
Correct Answer: A
Rationale: Step 1: Asking the patient to rate pain on a scale of 0 to 10 is a standard pain assessment tool, allowing for quantification and tracking of pain intensity.
Step 2: This question helps in understanding the severity of pain objectively.
Step 3: It provides a baseline for further pain management interventions.
Step 4: Other choices are incorrect as they do not directly address assessing pain intensity or severity.
Summary: Option A is the most appropriate as it focuses on quantifying pain, which is crucial for effective pain management. Choices B, C, and D are not as relevant for assessing pain intensity.
The nurse hears bilateral, louder, longer, and lower pitched tones when percussing over the lungs of a 4-year-old chilWhat should the nurse do next?
- A. Palpate over the area to identify increased pain and tenderness.
- B. Ask the child to take shallow breaths, and percuss over the area again.
- C. Refer the child immediately because of suspicion of an increased amount of air in the lungs.
- D. Consider this a normal finding for a child this age, and proceed with the examination.
Correct Answer: D
Rationale: The correct answer is D because in children, the lung sounds can be different due to their thinner chest walls and more prominent bronchial markings. The louder, longer, and lower-pitched tones heard upon percussion are normal findings in pediatric patients, indicating increased air content in the lungs. Palpating for pain or tenderness (choice A) is not necessary as these findings are expected in children. Asking the child to take shallow breaths and percussing again (choice B) is not needed as the initial findings are normal for the age group. Referring the child immediately (choice C) is unnecessary as these findings are within the normal range for a 4-year-old.
A nurse is caring for a patient who has undergone a total knee replacement. Which of the following interventions is most important to prevent post-operative complications?
- A. Encouraging early ambulation.
- B. Providing pain medication as needed.
- C. Monitoring for signs of infection.
- D. Administering antibiotics before surgery.
Correct Answer: A
Rationale: The correct answer is A: Encouraging early ambulation. Early ambulation helps prevent complications such as deep vein thrombosis and pulmonary embolism by improving circulation and preventing blood clots. It also promotes joint mobility and muscle strength. Providing pain medication (B) is important but not as crucial as preventing complications. Monitoring for signs of infection (C) is essential but not the most important intervention. Administering antibiotics before surgery (D) does not directly prevent post-operative complications related to knee replacement.
A nurse is teaching a patient about managing chronic obstructive pulmonary disease (COPD). Which of the following statements by the patient indicates the need for further education?
- A. I should avoid exposure to second-hand smoke.
- B. I will take my medications as prescribed.
- C. I can stop using my inhaler once I feel better.
- D. I will practice breathing exercises to improve my lung function.
Correct Answer: C
Rationale: The correct answer is C because stopping the inhaler once feeling better is incorrect. Inhalers are used to manage COPD symptoms long-term, not just when feeling unwell. Step 1: Explain that inhalers are essential for managing COPD and should be used consistently. Step 2: Emphasize that stopping inhaler use prematurely can lead to exacerbation of symptoms and worsening of the condition. Step 3: Reinforce the importance of following the prescribed treatment plan for optimal COPD management. Other choices are incorrect: A: True, avoiding second-hand smoke is crucial for COPD management. B: True, taking medications as prescribed is essential. D: True, breathing exercises can help improve lung function.
A nurse is caring for a patient who has undergone a colonoscopy. The nurse should prioritize monitoring for which of the following complications?
- A. Hypotension.
- B. Bleeding or perforation.
- C. Constipation.
- D. Pain at the insertion site.
Correct Answer: B
Rationale: The correct answer is B: Bleeding or perforation. After a colonoscopy, the patient is at risk for bleeding or perforation which are serious complications requiring immediate attention. Monitoring for signs such as abdominal pain, rectal bleeding, or signs of peritonitis is crucial. Choice A is not a priority unless the patient shows signs of shock. Choice C is a common post-procedure issue but not a priority complication. Choice D, pain at the insertion site, is expected and can be managed with analgesics.