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1. 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.
2. A nurse is teaching a client with heart failure about dietary restrictions. What food should be limited?
- A. Bananas
- B. Leafy green vegetables
- C. Potatoes
- D. Whole grains
Correct answer: A
Rationale: The correct answer is A: Bananas. Bananas are high in potassium, which should be limited in clients with heart failure to prevent electrolyte imbalances. While leafy green vegetables and whole grains are generally healthy options, they are not typically restricted in heart failure patients. Potatoes, although they contain potassium, are not as high in potassium as bananas and are not usually restricted as strictly.
3. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
- A. Apply counter-pressure for back pain
- B. Use deep breathing exercises
- C. Visualize the baby's head
- D. Use massage therapy
Correct answer: A
Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.
4. A nurse is caring for a client with a pressure ulcer and a serum albumin level of 3 g/dL. What should the nurse do first?
- A. Increase the client's protein intake
- B. Consult with a dietitian to improve the client's nutritional status
- C. Administer a protein supplement
- D. Monitor the client's fluid and electrolyte balance
Correct answer: B
Rationale: Consulting with a dietitian is the priority as it ensures that the client receives a comprehensive nutritional assessment and an individualized plan to address the low serum albumin level and pressure ulcer. Increasing protein intake (choice A) and administering a protein supplement (choice C) may be part of the dietitian's recommendations but should not be done without proper assessment and guidance. Monitoring fluid and electrolyte balance (choice D) is important but not the first step in addressing the client's nutritional needs.
5. How should a healthcare provider manage care for a patient with a wound infection?
- A. Administer prescribed antibiotics
- B. Clean the wound with saline
- C. Apply a sterile dressing
- D. Monitor for signs of sepsis
Correct answer: A
Rationale: When managing care for a patient with a wound infection, administering prescribed antibiotics is crucial. Antibiotics are necessary to treat the infection and prevent it from worsening. While cleaning the wound with saline and applying a sterile dressing are important components of wound care, the primary treatment for a wound infection is antibiotics. Monitoring for signs of sepsis is also essential, but administering antibiotics promptly is the most critical step in managing a wound infection.
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