Nokea
The nurse is providing discharge teaching to a client with asthma. Which statement indicates the client understands how to use a rescue inhaler?
- A. I will use my rescue inhaler every morning to prevent asthma attacks.
- B. I should use my rescue inhaler when I start to experience wheezing.
- C. I will use my rescue inhaler when my peak flow meter reading is in the green zone.
- D. I will only use my rescue inhaler before going to bed.
Correct Answer: B
Rationale: The correct answer is B: 'I should use my rescue inhaler when I start to experience wheezing.' A rescue inhaler is used during the onset of asthma symptoms, such as wheezing, to quickly open the airways. It is not intended for routine daily use or prevention, which is the role of a maintenance inhaler. Option A is incorrect because a rescue inhaler is not used for prevention but for immediate relief during an asthma attack. Option C is incorrect because the peak flow meter reading is used to monitor asthma control, not to determine when to use a rescue inhaler. Option D is incorrect because using a rescue inhaler only before going to bed does not address the need for immediate relief when wheezing or experiencing asthma symptoms.
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The nurse assesses a client's wound. What type of wound requires immediate intervention by the nurse?
- A. Laceration
- B. Abrasion
- C. Contusion
- D. Ulceration
Correct Answer: A
Rationale: Lacerations, especially deep ones, are prone to bacterial contamination and may require immediate intervention to prevent infection. Abrasions, contusions, and ulcerations are not as likely to lead to immediate serious complications like infections as lacerations.
Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
- A. White blood cell count.
- B. Prothrombin time (PT) and International Normalized Ratio (INR).
- C. Hemoglobin and hematocrit.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct Answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.
A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?
- A. Monitor for signs of bleeding, such as bruising.
- B. Monitor the client's vital signs every hour.
- C. Monitor for pain in the affected limb.
- D. Assess for signs of pulmonary embolism, such as sudden shortness of breath.
Correct Answer: D
Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.
The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?
- A. Decreased heart rate
- B. Increased appetite
- C. Cold intolerance
- D. Weight gain
Correct Answer: B
Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.
An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?
- A. Check the client's most recent electrolyte levels.
- B. Administer a PRN dose of muscle relaxant.
- C. Reduce the weight on the traction device.
- D. Encourage oral fluid intake to relieve muscle tension.
Correct Answer: D
Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.