Nokea
The nurse is teaching a client with a new diagnosis of asthma about the use of a spacer with a metered-dose inhaler. Which of the following instructions is most important?
- A. Shake the inhaler before attaching it to the spacer.
- B. Inhale quickly to maximize drug delivery.
- C. Clean the spacer with soap and water weekly.
- D. Use the spacer only during an asthma attack.
Correct Answer: C
Rationale: Cleaning the spacer weekly prevents bacterial buildup, ensuring safe and effective medication delivery.
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The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
- A. Place paper towels over the drops of liquid.
- B. Don clean gloves and wipe up the drops of liquid.
- C. Post 'wet floor' signs around the area.
- D. Call the Environmental Services Department.
Correct Answer: C
Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips. Then, the nurse can proceed with cleanup or notify appropriate personnel.
The nurse is assessing a newborn 24 hours after birth. Which finding requires immediate reporting?
- A. Milia on the nose
- B. Mongolian spots on the back
- C. Caput succedaneum
- D. Yellowing of the skin
Correct Answer: D
Rationale: Yellowing of the skin within 24 hours suggests pathological jaundice, requiring immediate evaluation to prevent complications like kernicterus.
Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.
- A. Extremities warm to touch.
- B. Improved respiratory status.
- C. Decreased muscle pain with activity.
- D. Participation in self-care measures.
- E. Lungs clear to auscultation.
Correct Answer: A,C,D
Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.
Your client has been getting total parenteral nutrition for bowel rest for the last four days. During your assessment of the client today, your client tells you that their 'chest hurts'. You assess that the client is also experiencing dyspnea. What is most likely occurring with this client?
- A. Your client may be experiencing a fluid overload.
- B. Your client may be experiencing an embolus.
- C. Your client may be hyperglycemic.
- D. Your client may have an inadvertent pneumothorax.
Correct Answer: B
Rationale: Chest pain and dyspnea in a client receiving TPN suggest a possible embolus, such as a pulmonary embolism, which is a serious complication requiring immediate attention.
The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?
- A. Administer surfactant
- B. Provide high-flow oxygen
- C. Initiate antibiotic therapy
- D. Perform chest physiotherapy
Correct Answer: A
Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.