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The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler four times a day.
- B. I have a dry mouth.
- C. I feel dizzy sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.
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The nurse is teaching a client who has short-term memory loss how to use the call light. Which factor is least essential for the nurse to assess when teaching this client?
- A. Visual status
- B. Ambulatory difficulty
- C. Orientation to time, place, and person
- D. Understanding of the English language
Correct Answer: B
Rationale: Ambulatory difficulty is least relevant, as call light use relies on vision, orientation, and language comprehension, not mobility.
A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
- A. Aspiration noted on honey thick diet.
- B. Pain with a bowel movement
- C. Pain felt in the left upper quadrant
- D. Right shoulder pain
Correct Answer: B
Rationale: Bowel movement pain should be examined with a colonoscopy not an endoscopy.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving salmeterol (Serevent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler twice a day.
- B. I have a dry mouth.
- C. I feel shaky sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Shakiness suggests systemic beta-agonist effects, a concerning side effect of salmeterol in COPD, requiring evaluation to prevent tachycardia or arrhythmias. Options A, B, and D are less concerning: twice-daily use is standard, dry mouth is common, and rinsing is appropriate.
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.