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A nurse is teaching a patient with asthma about managing triggers. Which of the following should the nurse emphasize to avoid asthma attacks?
- A. Using over-the-counter medications to control symptoms.
- B. Avoiding environmental allergens and smoking.
- C. Increasing physical activity to strengthen the lungs.
- D. Limiting fluid intake to reduce mucus production.
Correct Answer: B
Rationale: The correct answer is B: Avoiding environmental allergens and smoking. Environmental allergens and smoking are common triggers for asthma attacks. Avoiding these triggers can significantly reduce the risk of exacerbations. Over-the-counter medications may provide symptomatic relief but do not address the underlying triggers. Increasing physical activity can be beneficial but may also trigger asthma attacks in some individuals. Limiting fluid intake to reduce mucus production is not a recommended strategy for managing asthma triggers.
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How many teeth should an 18-month-old child have?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: The correct answer is C: 12. At 18 months, a child should have 12 teeth, which include 8 incisors and 4 molars. This is because children typically start teething around 6 months, with the lower central incisors coming first. By 18 months, they should have all 8 incisors and usually the first set of molars. Options A, B, and D are incorrect because they do not align with the typical dental development timeline for children. Having only 6, 8, or 16 teeth at 18 months would indicate a delay or abnormality in dental growth.
Which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.
When listening to a patient's breath sounds, the nurse is unsure about a sound that is hearThe nurse should:
- A. notify the patient's physician immediately.
- B. document the sound exactly as it was heard.
- C. validate the data by asking a colleague to listen to the breath sounds.
- D. assess again in 20 minutes to note whether the sound is still present.
Correct Answer: C
Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.
What is the most effective action when a client presents with acute shortness of breath and a history of COPD?
- A. Administer oxygen
- B. Administer antibiotics
- C. Monitor blood glucose
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.
What is the first action the nurse should take when a client presents with signs of respiratory distress?
- A. Open the airway
- B. Administer oxygen
- C. Administer medication
- D. Administer pain relief
Correct Answer: A
Rationale: The correct answer is A: Open the airway. This is the first action because in respiratory distress, ensuring a clear airway is crucial for adequate oxygenation. Opening the airway helps facilitate breathing and prevents further complications. Administering oxygen (choice B) can be done after ensuring the airway is clear. Administering medication (choice C) and pain relief (choice D) are not the initial priority in managing respiratory distress.