Nokea
The nurse is teaching the client the appropriate way to use a metered dose inhaler. Which observation indicates the client needs additional teaching?
- A. The client takes a deep breath while depressing the canister
- B. The client holds the canister two finger widths from the mouth
- C. The client waits 30 seconds before repeating the inhalation
- D. The client exhales slowly and deeply
Correct Answer: C
Rationale: When using a metered dose inhaler, the client should wait 1-2 minutes between puffs to ensure proper absorption, not 30 seconds. Answer C indicates a need for additional teaching. Answers A, B, and D describe correct techniques for inhaler use.
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The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.
- A. I will give the injection if my child has trouble breathing after a bee sting
- B. I will give the injection in the upper arm
- C. I will keep an epinephrine injection close to my child at all times
- D. I will take my child to the emergency room after giving the injection
- E. The injection can be given through clothing
Correct Answer: A,C,D,E
Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
- A. asking whether another individual wants to be her support person
- B. assuring her that the nursing triage group will be with her at all times
- C. telling her you will try to locate her family
- D. reinforcing the woman's confidence in her own abilities to cope and maintain a sense of control
Correct Answer: A
Rationale: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
A client has sustained second- and third-degree burns over her entire left arm and posterior trunk. Using the Rule of Nines, which percentage of the client's body is burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: C
Rationale: Per the Rule of Nines, one arm is 9% and the posterior trunk is 18%, totaling 27% body surface area burned.
The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.