Nokea
The nurse is teaching a client on the proper technique to use an inhaler with a spacer for asthma management. Which action by the client would require intervention by the nurse?
- A. The client shakes the unit vigorously 3 or 4 times.
- B. The client places the inhaler over his tongue and seals his lips tightly around it.
- C. The client administers the next puff immediately after exhaling.
- D. The client keeps his lips closed and holds his breath for at least 10 seconds before exhaling.
Correct Answer: B
Rationale: Placing the inhaler over the tongue obstructs the airway; lips should seal around the mouthpiece with the tongue underneath. Other actions are correct.
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The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That cannot be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
The nurse is assessing a client with a history of heart failure who is receiving furosemide (Lasix). Which of the following findings would indicate a need to withhold the medication?
- A. Potassium level of 2.8 mEq/L.
- B. Blood pressure of 130/80 mmHg.
- C. Heart rate of 80 beats per minute.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: hypokalemia is a side effect of furosemide; a potassium level of 2.8 mEq/L is low and requires intervention before administering the medication
An elderly client's wife tells a nurse she is concerned because her husband insists on talking about past events. The nurse assesses the client and finds him alert, oriented, and responsive to questions. Which statement should the nurse make to the client's wife?
- A. Your husband is choosing to live in a happier time in his life.
- B. Redirect your husband to speak about current events when he begins regressing into the past.
- C. If he were my husband, I would call our minister to speak to him.
- D. Your husband is reflecting on his life. This is normal at his age.
Correct Answer: D
Rationale: Reflecting on past events is a normal part of aging, especially in older adults, and this response reassures the wife while providing accurate information.
A client with pulmonary edema is ordered IV hydrocortisone (Solu-Cortef) 40 mg b.i.d. Which laboratory value would the nurse expect to see as a result of this therapy?
- A. elevated magnesium
- B. lowered magnesium
- C. elevated glucose
- D. lowered glucose
Correct Answer: C
Rationale: Hydrocortisone, a corticosteroid, increases blood glucose by promoting gluconeogenesis. Magnesium levels are not primarily affected.