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The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. Which of the following instructions should be included in the teaching?
- A. Rinse the mouth after each use of a steroid inhaler.
- B. Inhale quickly when administering the medication.
- C. Inhale the medication and then exhale through the nose.
- D. Cough and deep-breathe before inhaling the medication.
Correct Answer: A
Rationale: Rinsing the mouth after using a steroid inhaler prevents oral thrush, a common side effect. Quick inhalation, nasal exhalation, or coughing before use are not standard techniques.
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The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?
- A. Sitting with the arms over the head.
- B. Sims' position.
- C. Prone position without a pillow.
- D. Sitting forward with the arms supported on the bedside table.
Correct Answer: D
Rationale: Sitting forward with arms supported allows optimal access to the pleural space and ensures client comfort during thoracentesis.
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. The nurse monitors the client for relief of which symptom?
- A. Flatus
- B. Heartburn
- C. Rectal pain
- D. Muscle twitching
Correct Answer: B
Rationale: Calcium carbonate is used as an antacid for the relief of heartburn and indigestion. It can also be used as a calcium supplement or to bind phosphorus in the gastrointestinal tract in clients with renal failure. The remaining options are unrelated to this medication.
The nurse is assessing a client with suspected appendicitis. Which of the following findings supports this diagnosis?
- A. Pain at McBurney's point.
- B. Left lower quadrant pain.
- C. Decreased bowel sounds.
- D. Absence of fever.
Correct Answer: A
Rationale: Pain at McBurney's point (right lower quadrant) is a hallmark sign of appendicitis due to localized peritoneal irritation.
You are the supervising nurse in a physical rehabilitation center that has the philosophy that clients have the need to cope with their disabilities and its limitations are the result of a discrepancy between the client's abilities and the limitations of the physical and social environment within which the client lives. Which model of disability is this philosophy based on?
- A. Orem's Self Care Model
- B. Nagis Model
- C. A cognitive model of disability
- D. A biomedical model of disability
Correct Answer: C
Rationale: This philosophy aligns with the cognitive model of disability, which emphasizes the interaction between an individual's abilities and environmental barriers, focusing on adaptation and coping strategies.
Which client should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. A client who needs teaching regarding the use of an incentive spirometer
- B. A client who needs to have a urine specimen collected for a clean catch urine
- C. A client who needs reinforcement of a dressing covering an abdominal incision
- D. A client who needs assessment of a newly identified area of pressure over the right hip
Correct Answer: B
Rationale: The UAP can assist with specimen collection such as a clean catch urine because he or she is trained in this skill. Skills requiring nursing intervention such as dressing changes, teaching, and assessment cannot be delegated to unlicensed personnel.