Nursing Elites

1. When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?

• A. Shake the inhaler before use.
• B. Inhale quickly and deeply.
• C. Use the inhaler as needed.
• D. Do not use a spacer with the inhaler.

Correct answer: A

Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.

2. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?

• A. Massage the reddened area.
• B. Apply a donut-shaped cushion.
• C. Reposition the client every 3 hours.
• D. Use a transparent film dressing.

Correct answer: D

Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.

3. When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?

• A. Position the client with the head of the bed elevated to 30° prior to insertion
• B. Measure the tube from the client's nose to the earlobe to the xiphoid process
• C. Lubricate the entire length of the tube with water-soluble lubricant
• D. Instruct the client to cough during insertion

Correct answer: B

Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.

4. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

5. A client with a new diagnosis of pancreatitis is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of high-fat foods.
• B. You should decrease your intake of high-fat foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct statement the nurse should include in teaching a client with pancreatitis is to decrease the intake of high-fat foods. This dietary modification is crucial in managing symptoms and preventing exacerbations of pancreatitis. High-fat foods can put a strain on the pancreas, potentially leading to further complications. Choice A is incorrect because increasing intake of high-fat foods can worsen pancreatitis. Choice C is unrelated to pancreatitis management, as lactose intolerance is not directly linked to pancreatitis. Choice D is also incorrect, as increasing dairy product intake may not be suitable for all individuals with pancreatitis due to the fat content in many dairy products.

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