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1. What are the nursing priorities for a patient experiencing an asthma exacerbation?
- A. Administer a bronchodilator
- B. Encourage deep breathing
- C. Provide oxygen therapy
- D. Monitor oxygen saturation
Correct answer: A
Rationale: The correct nursing priority for a patient experiencing an asthma exacerbation is to administer a bronchodilator. Bronchodilators help in relieving bronchoconstriction and improving breathing. While encouraging deep breathing, providing oxygen therapy, and monitoring oxygen saturation are essential aspects of managing asthma exacerbation, the priority is to administer a bronchodilator to address the acute bronchoconstriction.
2. A client with active tuberculosis is receiving discharge instructions. Which statement by the client indicates an understanding of the teaching?
- A. I will continue taking my isoniazid until I am no longer contagious.
- B. I should take my prescribed medication for at least 6 months.
- C. I will need to have a TB skin test every 3 months.
- D. I should wear a mask at all times.
Correct answer: B
Rationale: The correct answer is B because the client should take antitubercular medications for a minimum of 6 months to ensure complete eradication of the infection. Choice A is incorrect as stopping the medication early can result in treatment failure and development of drug-resistant TB. Choice C is incorrect as regular TB skin tests are not needed once the client has been diagnosed and treated. Choice D is incorrect as wearing a mask at all times is not necessary for a client with active TB; proper cough etiquette should be followed instead.
3. A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?
- A. Provide lemon-glycerin swabs
- B. Encourage the client to eat soft foods
- C. Avoid using toothpaste
- D. Instruct the client to use a mouthwash containing alcohol
Correct answer: B
Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.
4. What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?
- A. Fluid restrictions are not needed for all clients with chronic kidney disease.
- B. You may need to limit fluid intake to prevent fluid overload.
- C. Fluid restrictions are based on your lab results and daily weights.
- D. Restricting fluids is only necessary during dialysis.
Correct answer: B
Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.
5. When teaching a client with left-leg weakness how to use a cane, which instruction should the nurse include?
- A. Use the cane on the weak side of the body
- B. Advance the cane and the strong leg simultaneously
- C. Maintain two points of support on the floor
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct answer: C
Rationale: The correct instruction for the client with left-leg weakness using a cane is to maintain two points of support on the floor. This ensures stability and balance while walking. Choice A is incorrect because the cane should be used on the strong side of the body to provide additional support. Choice B is incorrect as the cane and the weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
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