Nursing Elites

1. A client is being taught by a nurse about the correct use of a metered-dose inhaler (MDI). What instruction should the nurse include?

• A. Inhale for 1 second
• B. Hold the inhaler 1-2 inches from the mouth
• C. Exhale immediately after inhaling
• D. Hold the inhaler directly at the lips

Correct answer: B

Rationale: The correct instruction the nurse should include when teaching a client about using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance ensures proper delivery of the medication into the airways. Choices A, C, and D are incorrect because inhaling for a specific duration, exhaling immediately after inhaling, or holding the inhaler directly at the lips are not recommended practices for the correct use of an MDI.

2. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

3. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?

• A. Normal respiratory rate
• B. Nasal flaring
• C. Decreased breath sounds
• D. Increased breath sounds

Correct answer: B

Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.

4. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?

• A. Apply pressure directly to the wound
• B. Remove the dressings to assess the wound
• C. Use a clean dressing over the saturated one
• D. Apply alcohol to the wound

Correct answer: C

Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.

5. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the provider
• B. Recheck the blood pressure
• C. Administer antihypertensive medication
• D. Document the blood pressure in the chart

Correct answer: B

Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.

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