Nokea
In regards to question 10, which action by the patient demonstrates they know how to properly use this medication?
- A. The patient rinses their mouth after using the Spiriva inhaler.
- B. The patient rinses their mouth after using the Pulmicort inhaler.
- C. The patient dispenses of the inhalers.
- D. The patient coughs 2 times after using the Pulmicort inhaler.
Correct Answer: B
Rationale: Pulmicort (corticosteroid) requires mouth rinsing to prevent oral thrush. Spiriva doesn't require rinsing, and coughing or disposing are incorrect.
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Which nursing assessment is most important when caring for a client experiencing a severe allergic reaction?
- A. Taking the client's temperature
- B. Assessing the client's blood pressure
- C. Monitoring the client's respiratory status
- D. Checking the client's pupillary response
Correct Answer: C
Rationale: Monitoring respiratory status is critical during a severe allergic reaction, as anaphylaxis can cause airway obstruction and respiratory distress.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.
The nurse is feeding a client diagnosed with aspiration pneumonia who becomes dyspneic, begins to cough, and is turning blue. Which nursing intervention should the nurse implement first?
- A. Suction the client's nares.
- B. Turn the client to the side.
- C. Place the client in Trendelenburg position.
- D. Notify the health-care provider.
Correct Answer: B
Rationale: Dyspnea, coughing, and cyanosis suggest aspiration; turning to the side (B) clears the airway, preventing further aspiration. Suctioning (A), Trendelenburg (C), and notification (D) follow.
Which problem is appropriate for the nurse to identify for the client who is one (1) day postoperative thoracotomy?
- A. Alteration in comfort.
- B. Altered level of consciousness.
- C. Alteration in elimination pattern.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Pain (alteration in comfort, A) is a common issue post-thoracotomy due to surgical incision and chest tube placement, making it the most appropriate nursing diagnosis on day one. Altered consciousness (B) is not typical unless complications arise. Elimination issues (C) are less immediate. Knowledge deficit (D) is relevant later for discharge teaching.
Which statement indicates the client diagnosed with asthma needs more teaching concerning the medication regimen?
- A. I will take Singulair, a leukotriene, every day to prevent allergic asthma attacks.
- B. I need to use my Intal, cromolyn inhaler, 15 minutes before I begin my exercise.
- C. I need to take oral glucocorticoids every day to prevent my asthma attacks.
- D. If I have an asthma attack, I need to use my albuterol, a beta2 agonist, inhaler.
Correct Answer: C
Rationale: Daily oral glucocorticoids (C) are not typically used for asthma maintenance due to significant side effects; they are reserved for severe exacerbations or specific cases. Inhaled corticosteroids or leukotriene modifiers (like Singulair, A) are preferred for long-term control. Using cromolyn before exercise (B) is correct to prevent exercise-induced bronchospasm. Albuterol for acute attacks (D) is appropriate as a rescue inhaler.