Nokea
The client with chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should teach the client to:
- A. Take the medication with meals.
- B. Report blurred vision immediately.
- C. Use the inhaler every 2 hours as needed.
- D. Avoid drinking water after use.
Correct Answer: B
Rationale: Ipratropium, an anticholinergic bronchodilator, can cause blurred vision, a side effect requiring immediate reporting. It is not taken with meals, is used every 6–8 hours, and water restriction is unnecessary.
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The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Determine child's activity pattern
- B. Reduce mother's sense of guilt
- C. Instruct parents in use of ipecac
- D. Teach parents appropriate safety precautions
Correct Answer: D
Rationale: This goal is not the most important. There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. Ipecac is not used for caustic alkali and acid ingestions. Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
The nurse is caring for a client with a history of a pleural effusion who is scheduled for a thoracentesis. The nurse should:
- A. Position the client flat in bed
- B. Administer a sedative before the procedure
- C. Place the client in a sitting position
- D. Restrict fluids after the procedure
Correct Answer: C
Rationale: Sitting upright with arms supported facilitates access to the pleural space during thoracentesis and reduces complications. Sedatives and fluid restrictions are not routine.
A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:
- A. Initial maternal-infant bonding may be poor.
- B. Client may have a poor relationship with her husband.
- C. This response is normal in the first trimester.
- D. This response is abnormal, to be re-evaluated at the next visit.
Correct Answer: C
Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.
The nurse is teaching a mother care of her child's spica cast. The mother states that he complains of itching under the edge of the cast. One nonpharmacological technique the nurse might suggest would be:
- A. Blowing air under the cast using a hair dryer on cool setting often relieves itching.
- B. Slide a ruler under the cast and scratch the area.
- C. Guide a towel under and through the cast and move it back and forth to relieve the itch.
- D. Gently thump on cast to dislodge dried skin that causes the itching.
Correct Answer: A
Rationale: Cool air will often relieve pruritus without damaging the cast or irritating the skin. The nurse should never force anything under the cast, because the cast may become damaged and skin breakdown may occur. Forcing an object under the cast could lead to cast damage and skin breakdown. The object may become lodged under the cast necessitating cast removal. This technique does not dislodge skin cells. It could damage the cast and cause skin breakdown.
A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
- A. Weight gain
- B. Weight loss
- C. Tachycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.