The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

Depressing the MDI two times into the spacer before inhaling

Inhaling slowly through spacer and holding breath for 10 seconds

Holding breath for 30 seconds between inhalations

Inhaling then exhaling quickly into the spacer

Answer and Explanation

The Correct Answer is C

A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.

B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.

C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.

D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.

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Correct Answer is B

Explanation

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

A. "How long have you had the pain?" B. "Do you have a history of coronary artery disease?" C. "How would you describe your pain?" D. "What were you doing when the pain began?" E. "Can you rate your pain on a 0-10 scale?"

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

Explanation

A. "How long have you had the pain?"
Asking about the duration of the pain is crucial in assessing a myocardial infarction (MI). The length of time the pain has been occurring can help the nurse determine if the pain is acute or has been ongoing. For instance, chest pain lasting more than 20 minutes or worsening in intensity could indicate an MI. Knowing the timing of the pain also helps establish whether it may be related to acute coronary syndrome (ACS), which requires immediate intervention.

B. "Do you have a history of coronary artery disease?"
While it’s important to understand the patient’s medical history, this question is more secondary during the initial assessment of a client with chest pain. This information is valuable for understanding the risk of cardiovascular events, but it is not the immediate focus when assessing the current pain. The nurse should prioritize questions that address the current symptoms and the characteristics of the pain first.

C. "How would you describe your pain?"
This question is essential to help differentiate the chest pain associated with a myocardial infarction from other causes, such as musculoskeletal pain or gastrointestinal issues. MI pain is typically described as a crushing, pressure-like, or squeezing sensation. Identifying the quality of the pain helps establish whether it’s consistent with a cardiac event. Understanding the description of the pain also provides information about the intensity and potential for myocardial damage.

D. "What were you doing when the pain began?"
This is an important question because activity-related chest pain can help determine the potential cause of the pain. Pain associated with physical exertion or emotional stress may point to an MI or angina. On the other hand, pain unrelated to activity might suggest other causes such as gastrointestinal issues or musculoskeletal pain. Inquiring about the onset of the pain can also provide insight into whether it is associated with physical strain or acute coronary syndrome.

E. "Can you rate your pain on a 0-10 scale?"
Pain assessment using a numeric pain scale (0-10) helps the nurse gauge the severity of the pain and track changes over time. It’s important for determining whether the pain is severe enough to be consistent with an acute myocardial infarction or if it might resolve on its own. This information is vital in deciding the urgency of interventions and treatment decisions.

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The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care to a client admitted with a diagnosis of bacterial pneumonia. On assessment, the client has dry mucous membranes and coarse rhonchi. What nursing interventions would the nurse include in the plan of care?

Correct Answer is B

Explanation

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

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

Explanation

A client is admitted to the Emergency Department (ED) with a suspected ST elevation myocardial infarction (STEMI) involving the inferior wall. The nurse anticipates that this client will be immediately scheduled for the cardiac catheterization laboratory. The goal of treatment is to:

The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the provider immediately?

To achieve the outcome of effective ventilation, which nursing intervention should be included in the plan of care for a client on a ventilator?

The nurse is admitting a client who is on a ventilator. The client has a medical diagnosis of acute respiratory distress syndrome (ARDS). Which infection control guideline is of greatest importance?

To achieve the outcome of fall prevention at home in the client diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

A nurse is providing teaching to a client newly diagnosed with Parkinson's disease who is prescribed carbidopa/levodopa. What should be included in client teaching?

A client with a medical diagnosis of acute respiratory distress syndrome (ARDS) is being placed in the prone position. The nurse explains to family members that, "This will help improve ventilation by: