Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has a new prescription for an inhaler. Which of the following statements by the client indicates an understanding of the teaching?
A. I will shake the inhaler well before using it.
Shaking the inhaler well before using it is a correct action for the client to take, as it helps to mix the medication and the propellant. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
B. I will hold my breath for 10 seconds after inhaling the medication.
Holding the breath for 10 seconds after inhaling the medication is a correct action for the client to take, as it helps to keep the medication in the lungs and improve its absorption. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
C. I will rinse my mouth with water after using the inhaler.
Rinsing the mouth with water after using the inhaler is the best answer, as it indicates an understanding of the teaching. Rinsing the mouth with water helps to prevent oral thrush, a fungal infection that can occur as a side effect of some inhalers, especially those that contain steroids.
D. I will wait 30 seconds between each puff of the inhaler.
Waiting 30 seconds between each puff of the inhaler is not a correct action for the client to take, as it can reduce the effectiveness of the medication. The client should wait at least one minute between each puff of the inhaler, unless instructed otherwise by the provider.
This question is an excerpt from Nurse Dive's nursing test bank - NS117 T Winter 2023 Monroe college NY PN Fundamental of nursing proctored exam 2. Take the full exam now
Full Explanation
Choice A reason: Shaking the inhaler well before using it is a correct action for the client to take, as it helps to mix the medication and the propellant. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
Choice B reason: Holding the breath for 10 seconds after inhaling the medication is a correct action for the client to take, as it helps to keep the medication in the lungs and improve its absorption. However, it is not the best answer, as it is a general instruction that applies to most inhalers, not a specific one that indicates an understanding of the teaching.
Choice C reason: Rinsing the mouth with water after using the inhaler is the best answer, as it indicates an understanding of the teaching. Rinsing the mouth with water helps to prevent oral thrush, a fungal infection that can occur as a side effect of some inhalers, especially those that contain steroids.
Choice D reason: Waiting 30 seconds between each puff of the inhaler is not a correct action for the client to take, as it can reduce the effectiveness of the medication. The client should wait at least one minute between each puff of the inhaler, unless instructed otherwise by the provider.
Similar Questions
A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?
A. Rigid abdomen
Rigid abdomen is not a sign of diarrhea, but rather a sign of peritonitis, which is an inflammation of the abdominal lining. Peritonitis can be caused by a perforated ulcer, appendicitis, or diverticulitis.
B. Dehydration
Dehydration is a sign of diarrhea, as it indicates a loss of fluid and electrolytes from the body. Dehydration can cause symptoms such as dry mouth, thirst, decreased urine output, sunken eyes, and low blood pressure.
C. Hypothermia
Hypothermia is not a sign of diarrhea, but rather a sign of low body temperature. Hypothermia can be caused by exposure to cold, shock, or infection.
D. Decreased bowel sounds
Decreased bowel sounds are not a sign of diarrhea, but rather a sign of ileus, which is a lack of intestinal activity. Ileus can be caused by surgery, medication, or obstruction.
Full Explanation
Choice A reason: Rigid abdomen is not a sign of diarrhea, but rather a sign of peritonitis, which is an inflammation of the abdominal lining. Peritonitis can be caused by a perforated ulcer, appendicitis, or diverticulitis.
Choice B reason: Dehydration is a sign of diarrhea, as it indicates a loss of fluid and electrolytes from the body. Dehydration can cause symptoms such as dry mouth, thirst, decreased urine output, sunken eyes, and low blood pressure.
Choice C reason: Hypothermia is not a sign of diarrhea, but rather a sign of low body temperature. Hypothermia can be caused by exposure to cold, shock, or infection.
Choice D reason: Decreased bowel sounds are not a sign of diarrhea, but rather a sign of ileus, which is a lack of intestinal activity. Ileus can be caused by surgery, medication, or obstruction.
A nurse is providing teaching for a client who has an ileal conduit following bladder cancer. Which of the following statements by the client indicates a need for the nurse to provide additional teaching?
A. I need to catheterize the stoma several times a day.
This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
B. I will need to measure my stoma each week.
This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
C. I will always have to wear a pouch.
This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
D. I need to cleanse around the stoma with soap and water.
This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
Full Explanation
Choice A reason: This statement indicates a need for further teaching, as it is incorrect. The client does not need to catheterize the stoma, as the urine flows continuously from the ileal conduit to the pouch. Catheterization can cause infection and damage to the stoma.
Choice B reason: This statement is correct, as the client will need to measure the stoma each week for the first 6 to 8 weeks after surgery. The stoma may change in size and shape as it heals, and the client will need to adjust the size of the pouch opening accordingly.
Choice C reason: This statement is correct, as the client will always have to wear a pouch to collect the urine. The client can choose from different types of pouches, such as one-piece or two-piece systems, and change them as needed.
Choice D reason: This statement is correct, as the client will need to cleanse around the stoma with soap and water at least once a day. This helps to prevent skin irritation and infection. The client should avoid using alcohol, perfumes, or lotions on the stoma.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
A. Position the client supine.
Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
B. Cleanse the perineal area with an antiseptic.
Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
C. Deflate the balloon halfway and then pull out the catheter.
Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
D. Have the client bear down during removal.
Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
Full Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.