Nokea
The nurse is teaching a client with a new diagnosis of asthma about using an albuterol inhaler. Which of the following statements by the client indicates a need for further teaching?
- A. I should shake the inhaler before using it.
- B. I should hold my breath for 10 seconds after inhaling.
- C. I should use the inhaler every 4 hours even if I feel fine.
- D. I should rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Using albuterol every 4 hours without symptoms is incorrect, as it is a rescue inhaler for acute symptoms, not maintenance. Options A, B, and D are correct: shaking ensures proper dose, holding breath maximizes absorption, and rinsing prevents oral thrush (though more relevant for steroids).
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The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
- A. medicate the client for pain
- B. call the provider
- C. cover the wound with sterile saline dressing
- D. place the bed in a flat position
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.
The licensed practical nurse is caring for a 1-year old with a history of prematurity. Which developmental finding requires further evaluation by the physician?
- A. The child has been creeping for 3 months.
- B. The child can pull to a standing position.
- C. The child uses a pincer grasp.
- D. The child can sit with support.
Correct Answer: D
Rationale: Sitting with support at 1 year is delayed, especially for a preterm child, and requires evaluation. Creeping , standing , and pincer grasp are age-appropriate.
A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
A client has been taking propranolol (Inderal) 40 mg bid and furosemide (Lasix) 40 mg qd for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg tid to his medication regimen.
It is MOST important for the nurse to assess for which of the following?
- A. Tachycardia.
- B. Diarrhea.
- C. Peripheral edema.
- D. Impotence.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to medication. (1) will cause bradycardia (2) usually causes constipation (3) correct-Calan is a calcium-channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries, when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect