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The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.
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If a very active two year-old client pulls his tunneled central venous catheter out, what initial nursing action is appropriate?
- A. Obtain emergency equipment
- B. Assess heart rate, rhythm and all pulses
- C. Apply pressure to the vessel insertion site
- D. Use cold packs at the exit incision site
Correct Answer: C
Rationale: If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site to prevent bleeding and complications.
Which characteristic is most likely to be present in persons who abuse others?
- A. Financial security
- B. Positive self-image
- C. Substance abuse
- D. Physical illness
Correct Answer: C
Rationale: Substance abuse is strongly associated with abusive behavior due to impaired judgment and aggression. Financial security, self-image, or illness are less predictive.
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about hurting myself.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.