Nokea
The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to
- A. determine oxygen saturation
- B. measure forced expiratory volume
- C. monitor atmosphere for severe of allergens
- D. provide metered doses for inhaled bronchodilator
Correct Answer: B
Rationale: The peak flow meter is used to measure peak expiratory flow volume. It provides useful information about the presence and/or severity of airway obstruction.
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All of the following clients assigned to LPN/LVN ring their call bells. Which client needs the most immediate attention?
- A. A 72-year-old diabetic who is blind says she has to go to the bathroom.
- B. A 75-year-old client who has rheumatoid arthritis asks for pain medication.
- C. A client who has a blood transfusion running says her chest hurts.
- D. A postoperative client says he is in pain and wants a pain shot.
Correct Answer: C
Rationale: Chest pain during a blood transfusion suggests a possible transfusion reaction, a life-threatening emergency requiring immediate intervention. Bathroom needs, arthritis pain, or postoperative pain are less urgent.
An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.
- A. Put the tablets under your tongue and let them dissolve.
- B. Keep the tablets in a dark glass container.
- C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
- D. Be sure to take nitroglycerin while you are standing up.
- E. You may get a headache shortly after you take the medication,
- F. If your tongue tingles spit out the tablet.
Correct Answer: A,B,E
Rationale: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.
- A. Cradling my baby in my arms may cause stress and damage to the cast.'
- B. I will check my baby's toes several times a day to ensure that they are pink and warm.'
- C. My baby should alternate between sleeping on the stomach and back'
- D. My baby will need to have a new cast applied weekly for 5-8 weeks.'
- E. When I bathe or diaper my baby, I will be sure to keep the cast dry.'
Correct Answer: B, D, E
Rationale: Checking toes (B), weekly casts (D), and keeping the cast dry (E) are correct. Cradling (A) is safe, and alternating sleep positions (C) is not cast-related.