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A nurse is assisting in the care of a client.

Exhibits

Click to highlight the instructions the nurse should reinforce to the client.

Prescribed Medication

Nursing Instruction

Albuterol

"Take your albuterol when you are having difficulty breathing.”

"Hold your breath for 20 seconds when taking your albuterol.”

Salmeterol

"Take the salmeterol 5 minutes before the albuterol when you need both medications."

"Take the salmeterol 2 times each day."

Fluticasone

"Rinse out your mouth after taking the fluticasone."

"Take the fluticasone as needed for an asthma attack."

Take your albuterol when you are having difficulty breathing.

Hold your breath for 20 seconds when taking your albuterol.

Take the salmeterol 5 minutes before the albuterol when you need both medications.

Take the salmeterol 2 times each day.

Rinse out your mouth after taking the fluticasone.

Take the fluticasone as needed for an asthma attack.

Answer and Explanation

The Correct Answer is ["A","D","E"]

Albuterol

"Take your albuterol when you are having difficulty breathing.": Albuterol is a short-acting beta-agonist (SABA) used as a rescue inhaler for acute symptoms such as wheezing and shortness of breath.

"Hold your breath for 20 seconds when taking your albuterol.": This is incorrect as holding the breath for 10 seconds after inhalation is sufficient to allow the medication to reach the lungs. Holding it longer is unnecessary and impractical.

Salmeterol

"Take the salmeterol 2 times each day.": Salmeterol is a long-acting beta-agonist (LABA) intended for long-term control of asthma symptoms, not for acute attacks. It should be taken twice daily as prescribed.

"Take the salmeterol 5 minutes before the albuterol when you need both medications.": This is incorrect because salmeterol is not a rescue medication and should not be used for immediate relief. Albuterol should be taken first if both medications are prescribed together, allowing the airways to open for better absorption of salmeterol.

Fluticasone

"Rinse out your mouth after taking the fluticasone.": Fluticasone is an inhaled corticosteroid, and rinsing the mouth helps prevent oral thrush, a common side effect.

"Take the fluticasone as needed for an asthma attack.": This is incorrect because fluticasone is a maintenance medication for inflammation and is not effective for acute asthma attacks.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Dry cough: This is not typically associated with lithium toxicity and may indicate another issue, such as a respiratory infection.
B. Elevated blood pressure: Lithium toxicity usually results in hypotension, not elevated blood pressure.
C. Stooped posture: This is not a typical sign of lithium toxicity.
D. Slurred speech: Slurred speech can be an early sign of lithium toxicity, indicating that the medication level is too high.

A. Use the Z-track technique to administer the medication. B. Administer the medication with a 27-gauge 1/2-inch needle. C. Inject the medication at least 5 cm (2 in) from the umbilicus. D. Give the medication without aspirating prior to injection.

Correct Answer is A

Explanation

A. Use the Z-track technique to administer the medication.: The Z-track technique prevents irritation by sealing the medication within the muscle tissue.
B. Administer the medication with a 27-gauge 1/2-inch needle.: IM injections require a longer needle, typically 1–1.5 inches, and a larger gauge, such as 21–25.
C. Inject the medication at least 5 cm (2 in) from the umbilicus.: This is relevant for subcutaneous injections, not IM injections.
D. Give the medication without aspirating prior to injection.: Aspiration is not always required for IM injections but is often practiced for safety when administering certain medications.

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Body System	Findings
Vital Signs/General History	Temperature 35.4 °C (97.6 °F), oral Heart rate 75/min Respiratory rate 16/min Blood pressure 100/74 mmHg Oxygen saturation 99% on room air Client is a vegetarian and takes a multivitamin daily Client reports having three to four alcoholic beverages a couple times per week.
Integumentary	Skin color is consistent with genetic background. No rashes or lesions. The client has varicose veins.
Cardiovascular/Respiratory	S1S2 auscultated. No murmurs. All peripheral pulses 2+. Lung sounds clear bilaterally.
Gastrointestinal/Genitourinary	Abdomen soft, nontender. Normoactive bowel sounds in all 4 quadrants. Last bowel movement was 3 days ago. Voids four to five times a day. Urine is clear, yellow, and odorless. Last menstrual period was 3 months ago.
Neurologic/Musculoskeletal	Alert and oriented to person, place, and time. Client takes diazepam as needed for anxiety. Client has full range of motion and is able to maintain flexion against resistance in all four extremities.

Prescribed Medication	Nursing Instruction
Albuterol	"Take your albuterol when you are having difficulty breathing.” "Hold your breath for 20 seconds when taking your albuterol.”
Salmeterol	"Take the salmeterol 5 minutes before the albuterol when you need both medications." "Take the salmeterol 2 times each day."
Fluticasone	"Rinse out your mouth after taking the fluticasone." "Take the fluticasone as needed for an asthma attack."

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is collecting data from a client taking lithium. Which of the following information should the nurse report to the provider as an indication of lithium toxicity?

Correct Answer is D

Explanation

A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina. The nurse should inform the client that which of the following manifestations is an adverse effect of the medication?

A nurse is collecting data from a client who states she recently started taking garlic as an herbal supplement. The nurse should advise the client to stop taking garlic due to a potential reaction with which of the following client medications?

A nurse is caring for a client who has a new prescription for a nitroglycerin transdermal patch. Which of the following actions should the nurse take?

A nurse is caring for a client who is receiving an oral solution of codeine to suppress a nonproductive cough. Which of the following is the nurse's data collection priority following administration of this medication?

A nurse is reinforcing teaching about phenytoin with a client who had a tonic-clonic seizure. Which of the following information should the nurse include in the teaching?

A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?