Nokea
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
- A. Use the meter once a week.
- B. Record the highest of three readings.
- C. Clean the meter with soap daily.
- D. Use the meter only during an asthma attack.
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
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The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?
- A. Vital signs
- B. Motor function
- C. Sensory function
- D. Level of consciousness
Correct Answer: D
Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.
A 9-month-old child has been diagnosed with an ear infection. The father asks what else to do to help his child. The nurse can tell the father:
- A. Your child should also take an antihistamine.'
- B. The antibiotic is the only medicine necessary.'
- C. The ear in the ears helps the discomfort.'
- D. Over-the-counter eardrops often are helpful.'
Correct Answer: B
Rationale: Antibiotics are the primary treatment for bacterial ear infections; antihistamines and eardrops are not typically recommended unless prescribed.
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
- A. Cover the neonate's eyes.
- B. Apply lotion to the skin.
- C. Keep the neonate swaddled.
- D. Monitor urine output daily.
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
A client with a history of depression is prescribed paroxetine (Paxil). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Suicidal thoughts.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Suicidal thoughts are a serious side effect of paroxetine, requiring immediate reporting to ensure client safety.
A 4-year-old child is admitted with a tentative diagnosis of Kawasaki disease. Which of the following laboratory findings is most likely to be found in this child?
- A. Leukocytosis.
- B. Thrombocytopenia.
- C. Decreased sedimentation rate.
- D. Hypoalbuminemia.
Correct Answer: A
Rationale: Kawasaki disease is commonly associated with leukocytosis, reflecting the inflammatory process characteristic of the condition.