The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?
- A. I will exhale a complete breath as quickly as possible through the mouthpiece of the device to obtain a peak flow reading
- B. I will move the indicator to the desired reading on the numbered scale before using the device
- C. I will record the lowest of 3 consecutive peak flow readings in my asthma journal every day.
- D. I will remember to use the device after taking my fluticasone via metered-dose inhaler.
Correct Answer: A
Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.
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A client with cancer tells the nurse that he would like to make out a living will. The nurse knows that a living will provides documentation of:
- A. The client's desire to receive all means of assistance to sustain life.
- B. The client's desire to allow another to make decisions regarding his care.
- C. The client's wish to die without life-prolonging interventions.
- D. The client's desire to have his life terminated by active euthanasia.
Correct Answer: C
Rationale: A living will documents a client's wish to avoid life-prolonging interventions in terminal conditions. It does not mandate all assistance, delegate decisions, or support euthanasia.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?
- A. Client rates leg pain as '7'
- B. Negative Homan sign
- C. Prominent varicose veins bilaterally
- D. Right calf is 4 cm larger than left calf
Correct Answer: D
Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.
A nurse is reinforcing teaching to the parent of a 6 year-old with a urinary tract infection on how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply.
- A. I just bought my child new nylon panties.
- B. I will make sure my child does not hold urine.
- C. I will not give my child any more bubble baths.
- D. I will teach my child to wipe from the front to the back.
- E. I will use antibacterial soap for bathing my child.
Correct Answer: B,C,D
Rationale: Nylon panties can trap moisture, increasing infection risk; cotton is preferred. Not holding urine prevents bacterial growth. Avoiding bubble baths reduces irritation. Wiping front to back prevents bacterial spread. Antibacterial soap may disrupt natural flora, increasing infection risk.
The nurse is about to medicate a client who is to have surgery today. The client says, 'I do not understand what the doctor is going to do,' and asks the nurse to explain specific details of the surgery. The client has already signed an operative permit. What is the best action for the nurse to take at this time?
- A. Attempt to answer the client's questions
- B. Notify the physician of the client's concerns prior to medicating the client
- C. Reassure the client that the physician is well respected and very competent
- D. Suggest that the client ask the physician her questions when in the operating room
Correct Answer: B
Rationale: The client's lack of understanding indicates a need for clarification before proceeding. Notifying the physician ensures informed consent is valid, delaying medication that may impair judgment.