Nokea
Which action by the client should lead the nurse to determine the need for further teaching regarding the use of the incentive spirometer?
- A. Inhales slowly
- B. Breathes through the nose
- C. Removes the mouthpiece to exhale
- D. Forms a tight seal around the mouthpiece with the lips
Correct Answer: B
Rationale: Incentive spirometry is ineffective if the client breathes through the nose. The client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 5, and remove the mouthpiece to exhale. The client should repeat the exercise approximately 10 times every hour for best results.
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The nurse should tell the client to avoid which item while taking phenelzine sulfate?
- A. Blueberries
- B. Vasodilators
- C. Aged cheeses
- D. Digitalis preparations
Correct Answer: C
Rationale: Phenelzine sulfate is in the monoamine oxidase inhibitor (MAOI) class of antidepressant medications. An individual taking an MAOI must avoid aged cheeses, alcoholic beverages, avocados, bananas, and caffeine drinks. There are also other food items to avoid, including chocolate, meat tenderizers, pickled herring, raisins, sour cream, yogurt, and soy sauce. Medications that should be avoided include amphetamines, antiasthmatics, and certain antidepressants. The client should also avoid vasoconstrictors because their concurrent use can cause hypertensive crisis.
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
- A. unable to work simple toys
- B. unable to understand simple instructions
- C. unable to say first and last name
- D. unable to name any colors or numbers
Correct Answer: A,B,D
Rationale: By age 3, children should manipulate simple toys, follow simple instructions, and name some colors or numbers. These limitations (A, B, D) suggest developmental delays requiring further evaluation. Saying first and last name (C) is less critical at this age.
A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?
- A. Peaked T waves on the ECG
- B. Muscle spasms
- C. Constipation
- D. A prominent U wave on the ECG
Correct Answer: A
Rationale: A client with hyperkalemia may exhibit peaked T waves on an electrocardiogram. This manifestation is an early sign of high potassium levels, but diagnosis should not be based on this aspect alone. Untreated, hyperkalemia can lead to progressively worsening cardiac instability. Muscle spasms (Choice B) are more commonly associated with hypocalcemia. Constipation (Choice C) is not a typical sign of hyperkalemia. A prominent U wave on the ECG (Choice D) is associated with hypokalemia, not hyperkalemia.
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?
- A. I should not have ultrasounds done because I am diabetic.
- B. I'm glad I don't have to worry about developing hypoglycemia while I am pregnant.
- C. I need to watch my weight for any sudden gains because I could develop what they call gestational hypertension.
- D. My insulin needs should decrease during the last 2 months because I will be using some of the baby's insulin supply.
Correct Answer: C
Rationale: A diabetic pregnant client has a higher incidence of developing gestational hypertension than the nondiabetic pregnant client does. Ultrasounds are done frequently during a diabetic pregnancy to check for congenital anomalies and to determine appropriate growth patterns. Hypoglycemia is a problem during pregnancy in the client diagnosed with diabetes mellitus and needs to be assessed throughout the pregnancy. Insulin needs will increase during the last trimester because of increased hormone levels that destroy circulating insulin.