Nokea
The nurse is teaching a client with a new diagnosis of asthma about salmeterol (Serevent). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Report any tremors or shakiness.
- C. Stop the medication if symptoms improve.
- D. Avoid rinsing the mouth after use.
Correct Answer: B
Rationale: Tremors or shakiness indicate systemic beta-agonist effects, requiring reporting. Options A, C, and D are incorrect.
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A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated red blood cell count
- D. Increased glucose
Correct Answer: A
Rationale: High protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
An adult is admitted with histoplasmosis. What is most likely to be in the client's history because he has histoplasmosis?
- A. He is a chicken farmer.
- B. He ate raw shellfish recently.
- C. He consumed contaminated water.
- D. He drinks raw milk.
Correct Answer: A
Rationale: Histoplasmosis is caused by inhaling Histoplasma spores, often found in bird or bat droppings, common in chicken farming environments, unlike shellfish, water, or milk.
Which instruction should be given to the client taking alendronate sodium (Fosamax)?
- A. Take the medication before arising.
- B. Force fluids while taking this medication.
- C. Remain upright for 30 minutes after taking this medication.
- D. Take the medication in conjunction with estrogen.
Correct Answer: C
Rationale: Alendronate sodium is a drug used to treat osteoporosis. The drug causes gastric reflux, so the client should remain upright for 30 minutes after taking it and take it with only water. Taking it before arising or with estrogen is incorrect, and forcing fluids is not necessary.
A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being 'too sick to return to work.' The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior
- A. Is controlled by their subconscious mind
- B. Is manipulative to avoid work responsibilities
- C. Would respond to psychoeducational strategies
- D. Could be modified through reality therapy
Correct Answer: A
Rationale: Is controlled by their subconscious mind. Somatoform disorder involves involuntary physical complaints driven by psychological factors, not conscious manipulation.
A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended