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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 collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?
- A. Frequency
- B. Dosage
- C. Timing of doses
- D. Route
Correct answer: B
Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.
3. A nurse is preparing to administer a client's morning medications. Which of the following actions should the nurse take to verify the client's identity?
- A. Ask the client's full name
- B. Scan the client's facility identification band
- C. Call the client's name
- D. Verify with a second nurse
Correct answer: B
Rationale: The correct action to verify a client's identity when administering medications is to scan the client's facility identification band. This method ensures accuracy and helps prevent medication errors. Asking the client's full name (Choice A) may not be reliable as names can be similar, leading to confusion. Calling the client's name (Choice C) may not be effective if there are multiple clients with the same name in the facility. Verifying with a second nurse (Choice D) is an important safety measure for certain tasks but is not specifically for verifying a client's identity.
4. When caring for a client with a wound infection, what is the most important nursing action?
- A. Change the dressing every 4 hours
- B. Perform a wound culture before administering antibiotics
- C. Cleanse the wound with alcohol-based solutions
- D. Apply a wet-to-dry dressing to the wound
Correct answer: B
Rationale: Performing a wound culture before administering antibiotics is crucial in identifying the specific infecting organism and choosing the most effective antibiotic treatment. Changing the dressing every 4 hours (choice A) may be too frequent and can disrupt the wound healing process. Cleansing the wound with alcohol-based solutions (choice C) can be too harsh and may delay healing. Applying a wet-to-dry dressing (choice D) can cause trauma to the wound bed and is not recommended for infected wounds.
5. What are the nursing interventions for a patient with neutropenia?
- A. Monitor for signs of infection and administer antibiotics
- B. Isolate the patient and provide a low-microbial diet
- C. Monitor vital signs and avoid unnecessary invasive procedures
- D. Encourage the patient to engage in social activities
Correct answer: A
Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.
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