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Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective?
- A. I am going to use a regular-bristle toothbrush.
- B. I will take antibiotics prior to having my teeth cleaned.
- C. I can take enteric-coated aspirin for my headache.
- D. I will wear a Medic Alert band at all times.
Correct Answer: D
Rationale: A Medic Alert band (D) ensures emergency awareness of PE/anticoagulation. Multiple Choice toothbrushes (A) risk bleeding, antibiotics (B) are for endocarditis, and aspirin (C) increases bleeding.
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Which referral is most appropriate for a client diagnosed with end-stage COPD?
- A. The Asthma Foundation of America.
- B. The American Cancer Society.
- C. The American Lung Association.
- D. The American Heart Association.
Correct Answer: C
Rationale: The American Lung Association (C) supports COPD patients with resources. Asthma Foundation (A), Cancer Society (B), and Heart Association (D) are less relevant.
Which statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?
- A. I should wipe the container with an alcohol swab.
- B. I must not touch the inside of the container.
- C. I cannot put the lid on the container until the container is fairly full.
Correct Answer: B
Rationale: Not touching the inside of the container prevents contamination, ensuring an accurate sputum sample.
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
- A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
- B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
- C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
- D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.
Which assessment finding provides the best indication that the nurse needs to suction the client with a tracheostomy?
- A. Respirations are low.
- B. Pulse rate is slow.
- C. Breath sounds are wet.
- D. Blood pressure is elevated.
Correct Answer: C
Rationale: Wet breath sounds indicate mucus accumulation in the tracheostomy, necessitating suctioning to clear the airway.
When the client undergoes scratch skin testing, which sign best indicates a hypersensitivity to the scratched substance?
- A. The skin at the test site feels numb.
- B. The skin at the test site feels painful.
- C. The skin at the test site looks red.
Correct Answer: C
Rationale: A positive skin test reaction is indicated by redness and swelling at the test site, showing a hypersensitivity response to the allergen.