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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 who has hypertension about dietary modifications. Which of the following instructions should the nurse include?
- A. Increase sodium intake
- B. Reduce sodium intake to less than 1,500 mg per day
- C. Limit caffeine intake
- D. Increase caffeine intake to improve focus
Correct answer: B
Rationale: The correct answer is B: 'Reduce sodium intake to less than 1,500 mg per day.' For clients with hypertension, reducing sodium intake is crucial as it helps manage blood pressure. High sodium intake can lead to fluid retention and increased blood pressure. Choice A is incorrect because increasing sodium intake would worsen hypertension. Choice C is also correct as limiting caffeine intake is beneficial for managing hypertension. Choice D is incorrect as increasing caffeine intake can elevate blood pressure, which is detrimental for clients with hypertension.
3. What is the priority intervention when managing a client with delirium?
- A. Administer antipsychotic medication to calm the client
- B. Identify any reversible causes of delirium
- C. Provide a low-stimulation environment
- D. Administer sedative medication to control agitation
Correct answer: B
Rationale: The correct answer is to identify any reversible causes of delirium. Delirium is often caused by underlying issues such as infections, medication side effects, or metabolic imbalances. Addressing these root causes can help resolve delirium more effectively. Administering antipsychotic or sedative medications should not be the initial approach as they can worsen delirium in some cases. Providing a low-stimulation environment is beneficial but not the priority when reversible causes need to be addressed first.
4. What are the complications of untreated deep vein thrombosis (DVT)?
- A. Pulmonary embolism and stroke
- B. Kidney failure and hypertension
- C. Liver failure and electrolyte imbalance
- D. Fluid overload and bradycardia
Correct answer: A
Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.
5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?
- A. Serum glucose level.
- B. Serum calcium level.
- C. Lymphocyte count.
- D. Serum potassium level.
Correct answer: A
Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is an excess production of cortisol, leading to hyperglycemia. This results in an increase in serum glucose levels. Choices B, C, and D are incorrect because Cushing's disease does not directly affect serum calcium levels, lymphocyte count, or serum potassium levels.
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