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A nurse is teaching a guardian of a school-age child who has a new prescription for a fluticasone metered-dose inhaler. Which of the following information should the nurse include in the teaching? (SATA)
- A. Soak the inhaler in water after use.
- B. Have your child take one inhalation as needed for shortness of breath.
- C. Shake the device prior to administration.
- D. A spacer will make it easier to use the device.
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Shake the device prior to administration - Shaking the inhaler ensures proper mixing of the medication for effective delivery to the lungs.
D: A spacer will make it easier to use the device - A spacer helps improve medication delivery by ensuring more of the medication reaches the lungs rather than the mouth or throat.
E: - Additional information may include the importance of proper inhaler technique, how to clean the device, how to monitor for side effects, and when to seek medical help.
Incorrect Choices:
A: Soak the inhaler in water after use - Soaking the inhaler in water can damage the device and affect the medication's effectiveness.
B: Have your child take one inhalation as needed for shortness of breath - The prescription likely specifies a specific dosing regimen that should be followed, rather than using the inhaler as needed.
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A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
- A. Serpentine limb movement
- B. Shuffling gait
- C. Nonreactive pupils
- D. Smacking lips
Correct Answer: B
Rationale: The correct answer is B: Shuffling gait. Pseudoparkinsonism is a side effect of antipsychotic medications like haloperidol, characterized by symptoms similar to Parkinson's disease. A shuffling gait, which is a slow, dragging walk with short steps and reduced arm swing, is a classic manifestation. Serpentine limb movement (A) is not associated with pseudoparkinsonism. Nonreactive pupils (C) are not a typical symptom of pseudoparkinsonism. Smacking lips (D) is a sign of tardive dyskinesia, another side effect of antipsychotic medications.
A nurse is assessing a client who is taking an osmotic laxative. Which of the following findings should the nurse identify as an indication of fluid volume deficit?
- A. Nausea
- B. Weight gain
- C. Headache
- D. Oliguria
Correct Answer: D
Rationale: The correct answer is D: Oliguria. Osmotic laxatives, such as lactulose or polyethylene glycol, work by drawing water into the colon to soften the stool. If a client on osmotic laxatives is experiencing oliguria (decreased urine output), it can be a sign of fluid volume deficit due to the body trying to conserve water. Nausea (A) is a common side effect of osmotic laxatives but not a specific indicator of fluid volume deficit. Weight gain (B) is not associated with fluid volume deficit. Headache (C) can be caused by various factors and is not a specific sign of fluid volume deficit.
A client who has active tuberculosis and is taking rifampin reports that his urine and sweat have developed a red tinge. Which of the following actions should the nurse take?
- A. Check the client's liver function test results.
- B. Instruct the client to increase his fluid intake.
- C. Document this as an expected finding.
- D. Prepare the client for dialysis.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Document this as an expected finding. Rifampin is known to cause harmless discoloration of bodily fluids like urine and sweat. This is a common side effect and does not indicate any serious issues. The nurse should document this finding to track the client's response to the medication and educate the client about it.
Summary of Incorrect Choices:
A: Checking liver function test results is not necessary for the red discoloration caused by rifampin.
B: Increasing fluid intake will not resolve the red tinge as it is a known side effect of rifampin.
D: Dialysis is not indicated for the harmless discoloration caused by rifampin.
A nurse is assessing a client who is receiving a peripheral IV infusion and notes infiltration of fluid into the tissue surrounding the insertion site. Which of the following actions should the nurse take?
- A. Flush the IV catheter
- B. Apply pressure to the IV site
- C. Elevate the extremity
- D. Slow the infusion rate
Correct Answer: C
Rationale: The correct action is to elevate the extremity. Elevating the extremity above the level of the heart helps to reduce swelling and prevent further fluid infiltration into the surrounding tissue. This promotes proper circulation and limits potential complications. Flushing the IV catheter (choice A) would not address the infiltration issue. Applying pressure to the IV site (choice B) could cause further damage to the tissue. Slowing the infusion rate (choice D) may not be sufficient to prevent further infiltration.
A nurse is assessing a client's IV infusion site and notes that the site is cool and edematous. Which of the following actions should the nurse take?
- A. Slow the IV solution rate
- B. Initiate a new IV distal to the initial site
- C. Maintain the extremity below the level of the heart
- D. Apply a warm, moist compress
Correct Answer: D
Rationale: The correct action is to apply a warm, moist compress (Choice D). This helps improve circulation and reduce edema by promoting vasodilation and enhancing tissue perfusion. Cooling and edematous IV sites indicate impaired circulation, which can lead to complications like phlebitis. Slowing the IV rate (Choice A) may not address the underlying issue. Initiating a new IV distal to the initial site (Choice B) may not improve circulation in the affected area. Maintaining the extremity below heart level (Choice C) can worsen edema.