Nokea
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective?
- A. I'll be careful not to shake the canister before using it.
- B. It's important to hold the canister upside down when using it.
- C. I have to remember to inhale the medication through my nose.
- D. I will continue to inhale when the cold propellant is in my throat.
- E. I won't inhale more than one spray with one breath.
- F. I will activate the device while continuing to inhale.
Correct Answer: D,E,F
Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.
You may also like to solve these questions
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
- A. Instructing the assistant to notify the health care team
- B. Assessing the patient's vital signs
- C. Removing the tape, adjusting the depth to the ordered depth, and retaping securely
- D. Taking no action, as the depth will adjust automatically
Correct Answer: C
Rationale: The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
- A. Place the patient in Fowler position.
- B. Encourage diaphragmatic breathing.
- C. Ask the patient to cough.
- D. Initiate oral suctioning of secretions.
Correct Answer: A
Rationale: Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
- A. Bronchial
- B. Bronchovesicular
- C. Vesicular
- D. Wheezing
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.
A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
- A. Assessing the need to premedicate with an analgesic
- B. Placing the patient in low Fowler position
- C. Inserting the obturator into the outer cannula
- D. Maintaining aseptic technique
Correct Answer: D
Rationale: Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.