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A nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?
- A. The oxygen should be kept in a storage room when not in use.
- B. Turn off the oxygen when not in use.
- C. Check the oxygen level regularly using a pulse oximeter.
- D. Never leave the oxygen running when transporting a client.
Correct Answer: C
Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.
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A client receiving chemotherapy is being taught about infection prevention by a nurse. Which of the following instructions should the nurse include?
- A. Wear a mask when gardening.
- B. Avoid crowds to reduce the risk of infection.
- C. You should take a daily vitamin to prevent infection.
- D. Increase your intake of high-protein foods.
Correct Answer: B
Rationale: The correct answer is B: 'Avoid crowds to reduce the risk of infection.' Clients receiving chemotherapy are immunocompromised, so avoiding crowds can help decrease the likelihood of exposure to infections. Wearing a mask when gardening (choice A) is important but not directly related to infection prevention in the context of chemotherapy. Taking a daily vitamin (choice C) may be beneficial for overall health but is not specifically focused on infection prevention. Increasing intake of high-protein foods (choice D) is essential for nutrition but does not directly address infection prevention.
A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?
- A. Encourage the client to increase dietary fiber.
- B. Maintain the client on a low-residue diet.
- C. Provide the client with frequent high-calorie snacks.
- D. Encourage the client to eat a high-fiber diet.
Correct Answer: B
Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.
A nurse is teaching a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. "You can take this medication with a full glass of water."
- B. "You should store this medication in the refrigerator."
- C. "Take one tablet every 5 minutes until the pain is relieved, up to three doses."
- D. "You should avoid eating foods high in sodium while taking this medication."
Correct Answer: C
Rationale: The correct statement the nurse should include is to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is important to manage angina attacks effectively. Option A is incorrect because nitroglycerin sublingual tablets should not be taken with water. Option B is incorrect as nitroglycerin tablets should be stored in their original container at room temperature. Option D is incorrect because there is no specific instruction to avoid foods high in sodium while taking nitroglycerin sublingual tablets.
A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?
- A. There is no fluctuation in the water seal chamber.
- B. There is continuous bubbling in the suction control chamber.
- C. There is tidaling in the water seal chamber.
- D. The drainage system is positioned at the level of the client's chest.
Correct Answer: A
Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.
A nurse is caring for a client who has a new diagnosis of rheumatoid arthritis. Which of the following laboratory findings should the nurse expect?
- A. Increased WBC count.
- B. Decreased hemoglobin.
- C. Decreased platelet count.
- D. Positive rheumatoid factor.
Correct Answer: D
Rationale: The correct answer is D: Positive rheumatoid factor. A positive rheumatoid factor is a common laboratory finding in clients with rheumatoid arthritis, indicating an autoimmune response. Option A, increased WBC count, is not typically associated with rheumatoid arthritis. Option B, decreased hemoglobin, and option C, decreased platelet count, are not specific laboratory findings for rheumatoid arthritis.