Nokea
A nurse is reinforcing teaching with a client about the use of budesonide for asthma management. Which of the following statements by the adolescent indicates an understanding of the teaching?
- A. I will take my inhaler treatment before each meal and at bedtime.
- B. I should use my inhaler before exercising.
- C. I should use my inhaler when I have an asthma attack.
- D. I will rinse my mouth and gargle with water after each inhaler treatment.
Correct Answer: D
Rationale: Rinsing the mouth after budesonide use prevents oral thrush, a key self-care step. Budesonide isn't timed with meals, used before exercise routinely, or for acute attacks.
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A nurse is caring for a client who is postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?
- A. The client reports mild abdominal discomfort.
- B. The client's bowel sounds are hypoactive.
- C. The client's incision is red and warm to the touch.
- D. The client has passed flatus.
Correct Answer: C
Rationale: Redness and warmth at the incision suggest infection, requiring prompt reporting. Mild discomfort, hypoactive sounds, and flatus are expected post-resection.
A nurse is caring for a client who is receiving magnesium sulfate IV for preeclampsia. Which of the following findings indicates the medication is effective?
- A. Increased blood pressure
- B. Decreased respiratory rate
- C. Increased urine output
- D. Decreased deep tendon reflexes
Correct Answer: C
Rationale: Magnesium sulfate promotes diuresis, so increased urine output indicates effectiveness in managing fluid overload in preeclampsia.
A nurse is caring for a client who is postoperative following a coronary artery bypass graft. Which of the following actions should the nurse take?
- A. Encourage the client to cough and deep breathe every 2 hr.
- B. Instruct the client to avoid using their arms for support.
- C. Apply a warm compress to the chest incision.
- D. Allow the client to resume a high-sodium diet.
Correct Answer: A
Rationale: Coughing and deep breathing prevent atelectasis and pneumonia. Arm use is encouraged with guidance, warm compresses risk infection, and sodium is restricted.
A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert an oral airway into the client's mouth.
- B. Lower the side rails of the bed when the seizure begins.
- C. Measure the duration of the seizure.
- D. Restrain the client's arms and legs to prevent injury.
Correct Answer: C
Rationale: Measuring seizure duration aids in assessing severity and guiding treatment. Inserting airways, lowering rails, or restraining can cause injury or complications.
A nurse is caring for a client who is receiving IV gentamicin. Which of the following findings should the nurse report to the provider?
- A. The client reports mild nausea.
- B. The client's urine output is 30 mL/hr.
- C. The client's hearing has decreased.
- D. The client's blood pressure is 120/78 mm Hg.
Correct Answer: C
Rationale: Decreased hearing suggests ototoxicity, a serious gentamicin side effect requiring reporting. Nausea, low urine output, and normal BP are less urgent.