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1. A nurse is delegating the collection of a sputum specimen to an assistive personnel (AP). At which of the following times should the nurse instruct the AP to collect the specimen?
- A. In the afternoon
- B. As soon as the client awakens in the morning
- C. Before bedtime
- D. Immediately after lunch
Correct answer: B
Rationale: The correct answer is B: 'As soon as the client awakens in the morning.' Sputum specimens should be collected early in the morning to obtain a concentrated sample. This timing ensures that the specimen is less diluted, providing a more accurate analysis. Choices A, C, and D are incorrect as they do not align with the optimal timing for collecting a sputum specimen, which is in the morning.
2. A nurse is caring for a client who is scheduled for a bronchoscopy. Which of the following findings should the nurse report to the provider?
- A. The client is anxious about the procedure.
- B. The client has not eaten for 8 hours.
- C. The client has a reported allergy to shellfish.
- D. The client has a platelet count of 100,000/mm³.
Correct answer: D
Rationale: The correct answer is D. A platelet count of 100,000/mm³ is low and increases the risk of bleeding during the bronchoscopy. This finding should be reported to the provider for further evaluation and possible intervention. Choices A, B, and C are not as critical in this situation. Anxiety about the procedure is common and can be managed with appropriate interventions. Not eating for 8 hours is a standard pre-procedure requirement to prevent aspiration during sedation. A reported allergy to shellfish is important to note but is not directly related to the risk of complications during a bronchoscopy.
3. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
- A. Tachycardia
- B. Hypotension
- C. Increased urine output
- D. Diarrhea
Correct answer: C
Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice A) and hypotension (choice B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice D) can worsen dehydration and is not a positive response to IV fluid therapy.
4. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?
- A. Perform the test in the morning after taking medications
- B. Blow into the meter as slowly as possible
- C. Perform the test when feeling short of breath
- D. Use the peak flow meter after using your rescue inhaler
Correct answer: D
Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.
5. A healthcare provider is providing discharge teaching to a client who is recovering from acute pancreatitis. Which of the following instructions should the healthcare provider include?
- A. Consume a low-fat diet.
- B. Limit your carbohydrate intake.
- C. Increase your protein intake.
- D. Take acetaminophen for pain management.
Correct answer: A
Rationale: Clients recovering from acute pancreatitis should consume a low-fat diet to reduce the workload on the pancreas and prevent exacerbation. This diet helps in minimizing the stimulation of pancreatic enzyme secretion, which aids in the recovery process. Choices B, C, and D are incorrect as limiting carbohydrate intake or increasing protein intake may not be necessary for acute pancreatitis, and acetaminophen may not be the first-line choice for pain management in this condition.
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