1. A nurse is caring for a client who is postoperative and is refusing to
use the incentive spirometer. Which of the following should the nurse
do first? a) Administer pain medication to the client b) Explain the
importance of using the incentive spirometer to prevent pneumonia c)
Suggest that the client try deep breathing exercises instead d) Ask the
client to demonstrate the correct use of the incentive spirometer
Answer: b) Explain the importance of using the incentive spirometer to
prevent pneumonia
Rationale: Educating the client on the importance of using the
incentive spirometer to prevent complications like pneumonia is the
first step. It helps to explain why the intervention is necessary for their
recovery.
2. A nurse is providing discharge instructions to a client who has been
diagnosed with hypertension. Which of the following statements by the
client indicates the need for further teaching? a) "I will take my
medication at the same time every day." b) "I will reduce my salt intake
and exercise regularly." c) "I can stop my medication once my blood
pressure returns to normal." d) "I will monitor my blood pressure at
home as instructed."
Answer: c) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. The client should not stop their medication even if their
,blood pressure appears normal, unless directed by the healthcare
provider.
3. A nurse is teaching a client with a new diagnosis of hypertension
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
4. A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take first? a)
Encourage the client to talk about their feelings b) Provide a calming,
quiet environment c) Administer prescribed anti-anxiety medication d)
Encourage the client to deep breathe slowly and deeply
Answer: d) Encourage the client to deep breathe slowly and deeply
Rationale: Breathing exercises can help the client regain control and
manage the acute symptoms of a panic attack. This should be the first
action to reduce anxiety.
, 5. A nurse is preparing to administer a dose of oral medication to a
client with difficulty swallowing. Which of the following actions should
the nurse take? a) Crush the medication and mix it with food or liquid
b) Administer the medication with a glass of water c) Check if the
medication can be given through a feeding tube d) Ask the client to
chew the medication thoroughly
Answer: c) Check if the medication can be given through a feeding tube
Rationale: Some medications should not be crushed or mixed with food
or liquids because it can affect their absorption or effectiveness. The
nurse should check if the medication is safe to administer through a
feeding tube.
6. A nurse is teaching a client with asthma about the proper use of a
metered-dose inhaler (MDI). Which of the following actions indicates
that the client understands the instructions? a) "I will hold my breath
for 5 seconds after inhaling the medication." b) "I will exhale deeply
before inhaling the medication." c) "I will shake the inhaler for 10
seconds before each use." d) "I will inhale the medication with a fast
and deep breath."
Answer: c) "I will shake the inhaler for 10 seconds before each use."
Rationale: Shaking the inhaler before use ensures the medication is
properly mixed. It is also essential to exhale before inhaling, but the
key is ensuring proper technique.
7. A nurse is caring for a client with pancreatitis. Which of the
following is most important to monitor for? a) Respiratory rate b)
Serum calcium levels c) Blood glucose levels d) Liver function tests
use the incentive spirometer. Which of the following should the nurse
do first? a) Administer pain medication to the client b) Explain the
importance of using the incentive spirometer to prevent pneumonia c)
Suggest that the client try deep breathing exercises instead d) Ask the
client to demonstrate the correct use of the incentive spirometer
Answer: b) Explain the importance of using the incentive spirometer to
prevent pneumonia
Rationale: Educating the client on the importance of using the
incentive spirometer to prevent complications like pneumonia is the
first step. It helps to explain why the intervention is necessary for their
recovery.
2. A nurse is providing discharge instructions to a client who has been
diagnosed with hypertension. Which of the following statements by the
client indicates the need for further teaching? a) "I will take my
medication at the same time every day." b) "I will reduce my salt intake
and exercise regularly." c) "I can stop my medication once my blood
pressure returns to normal." d) "I will monitor my blood pressure at
home as instructed."
Answer: c) "I can stop my medication once my blood pressure returns
to normal."
Rationale: Hypertension is a chronic condition that requires ongoing
management. The client should not stop their medication even if their
,blood pressure appears normal, unless directed by the healthcare
provider.
3. A nurse is teaching a client with a new diagnosis of hypertension
about lifestyle modifications. Which of the following statements by the
client indicates understanding? a) "I will increase my intake of salt to
help regulate my blood pressure." b) "I will exercise for at least 30
minutes most days of the week." c) "I will stop drinking water and only
drink caffeinated beverages." d) "I will avoid eating foods high in fiber
to keep my blood pressure normal."
Answer: b) "I will exercise for at least 30 minutes most days of the
week."
Rationale: Regular exercise is an important lifestyle modification for
managing hypertension. It can help lower blood pressure and improve
overall cardiovascular health.
4. A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take first? a)
Encourage the client to talk about their feelings b) Provide a calming,
quiet environment c) Administer prescribed anti-anxiety medication d)
Encourage the client to deep breathe slowly and deeply
Answer: d) Encourage the client to deep breathe slowly and deeply
Rationale: Breathing exercises can help the client regain control and
manage the acute symptoms of a panic attack. This should be the first
action to reduce anxiety.
, 5. A nurse is preparing to administer a dose of oral medication to a
client with difficulty swallowing. Which of the following actions should
the nurse take? a) Crush the medication and mix it with food or liquid
b) Administer the medication with a glass of water c) Check if the
medication can be given through a feeding tube d) Ask the client to
chew the medication thoroughly
Answer: c) Check if the medication can be given through a feeding tube
Rationale: Some medications should not be crushed or mixed with food
or liquids because it can affect their absorption or effectiveness. The
nurse should check if the medication is safe to administer through a
feeding tube.
6. A nurse is teaching a client with asthma about the proper use of a
metered-dose inhaler (MDI). Which of the following actions indicates
that the client understands the instructions? a) "I will hold my breath
for 5 seconds after inhaling the medication." b) "I will exhale deeply
before inhaling the medication." c) "I will shake the inhaler for 10
seconds before each use." d) "I will inhale the medication with a fast
and deep breath."
Answer: c) "I will shake the inhaler for 10 seconds before each use."
Rationale: Shaking the inhaler before use ensures the medication is
properly mixed. It is also essential to exhale before inhaling, but the
key is ensuring proper technique.
7. A nurse is caring for a client with pancreatitis. Which of the
following is most important to monitor for? a) Respiratory rate b)
Serum calcium levels c) Blood glucose levels d) Liver function tests
