Nokea
The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from first to last?
- A. Inhale through an open mouth.
- B. Breathe out through the mouth.
- C. Hold the breath for 5 to 10 seconds.
- D. Press the canister to release the medication.
Correct Answer: B,D,A,C
Rationale: Exhale, press canister, inhale, and hold breath ensures proper medication delivery.
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A nurse is teaching parents about reducing lead exposure in their home. Which of the following should be included?
- A. Use only bottled water for drinking.
- B. Remove all carpeting from the home.
- C. Regularly wet-mop floors and surfaces.
- D. Replace all windows with new ones.
Correct Answer: C
Rationale: Wet-mopping reduces lead dust, a common exposure source. Bottled water is unnecessary unless water is contaminated, carpeting removal is excessive, and window replacement is costly and not always needed.
When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following?
- A. Ultra-high-frequency sound waves.
- B. Catheter placed in the right femoral vein.
- C. Cutdown procedure to place a catheter.
- D. General anesthesia.
Correct Answer: B
Rationale: Cardiac catheterization involves inserting a catheter, typically through the femoral vein, to assess heart structures. Ultra-high-frequency sound waves are used in echocardiography, a cutdown is not standard, and general anesthesia is not always required.
The nurse is caring for an infant with a temporary colostomy due to Hirschsprung's disease. Which of the following indicates proper stoma care?
- A. Cleaning the stoma with alcohol.
- B. Keeping the stoma dry and exposed.
- C. Applying a barrier cream around the stoma.
- D. Covering the stoma with a sterile dressing.
Correct Answer: C
Rationale: A barrier cream protects the skin around the stoma from irritation.
When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, which of the following would be most helpful in facilitating parent-infant bonding?
- A. Explaining to the parents that they can visit at any time.
- B. Encouraging the parents to hold their infant.
- C. Asking the parents to help monitor the infant's intake and output.
- D. Helping the parents plan for their infant's discharge.
Correct Answer: B
Rationale: Physical contact through holding fosters bonding and emotional connection.
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply.
- A. Coughing.
- B. Respiratory rate of 35 breaths/minute.
- C. Heart rate of 95 beats/minute.
- D. Restlessness.
- E. Malaise.
- F. Diaphoresis.
Correct Answer: B,D,F
Rationale: A respiratory rate of 35 breaths/minute (elevated for a toddler), restlessness, and diaphoresis indicate respiratory distress, reflecting increased work of breathing and stress. Coughing may be present but is less specific, while a heart rate of 95 bpm and malaise are not directly indicative of acute respiratory distress.