1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the client to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” Answer#2 2. An older client is scheduled for a magnetic resonance imaging MRI procedure. Which of the following statements, if made by the client to the nurse, should be reported to the technician before the test? 1. “I take medication to control my blood pressure” 2. “I have had diabetes for about 10 years now” 3. “I had a knee replacement 5 years ago” 4. “I am allergic to penicillin and sulfa medications” Answer#3 3. The nurse makes the following observations of a 6 hour old newborn: axillary temperature 96.4 F (35.8 C), apical pulse 148, respirations irregular at 48/minute, black sticky stool, blood glucose 60mg/dL. It is most important for the nurse to take which action? 1. Feed the newborn 30mL of infant formula 2. Administer low flow oxygen to the newborn 3. Wrap the newborn in a warmed blanket 4. Perform a guaiac test on the newborns stool Answer#3 4. A client is returned to the unit at 10AM after laparoscopic gallbladder surgery. The nurse plans to get the patient out of bed for the first time at 4PM. It is MOST important for the nurse to take which of the following actions? 1. Turn the patient from side to side at 2 PM 2. Offer pain medication to the patient at 3:30PM 3. Encourage the patient to use the incentive spirometer at 3PM 4. Cough and deep-breathe the patient at 2:30PM Answer#1 5. The activity therapy staff takes a group of psychiatric patients on a trip to the zoo. The nurse should intervene with which of the following patients before their departure? 1. A 50 year old female who is having difficulty with sleeping, eating, and social interaction. 2. A 40 year old male who just received his third dose of trazodone (Desyrel) and is 20 pounds overweight. 3. A 42 year old female who has problems with decision making who paces continuously, wringing her hands. 4. A 38 year old female who is receiving chlorpromazine (Thorazine) and is wearing a sundress without a hat or sunglasses. Answer#4 (photosensitivity;causes sensitivity to sun) 6. A patient experiences skin eruptions due to an allergic reaction to a medication. The nurse demonstrates the BEST documentation with which of the following? 1. “Patient complains of rash and itching over most of his body. Patient is concerned about how it looks” 2. “Multiple red welts noted over trunk and both arms. Patient states that welts itch” 3. “Allergic skin reaction to medication experienced by patient. Started several hours ago” 4. “Vital signs stable. Patient scratching arms and chest area frequently” Answer#2 7. An older client diagnosed with emphysema is admitted to the psychiatric unit for treatment of bipolar disorder. The client receives oxygen per nasal cannula. The client expresses concern to the nurse that someone will come in and change the amount of oxygen the client is receiving. INITIALLY, the nurse should take which of the following actions? 1. Schedule an in-service with the staff about emphysema 2. Place a sign above the patient’s bed stating that the oxygen level is not to be changed 3. Tell the patient she will be well cared for in the hospital 4. Convey the patient’s concern to the nursing staff Answer#2 8. A teenager has a positive home pregnancy test and comes to the prenatal clinic. The girl is uncertain of the date of her last menstrual period. The nurse palpates the uterine fundus midway between the symphysis pubis and the umbilicus. Which statement by the nurse is BEST? 1. “You are 24 weeks pregnant. It is good that you came in for prenatal care” 2. “You are 30 weeks pregnant. Prenatal care is important for you and your baby” 3. “You are 16 weeks pregnant. Let’s talk about what that means” 4. “You are 8 weeks pregnant. Are your periods usually irregular?” Answer#3 9. A client is admitted to the psychiatric unit with complaints of fatigue, inability to concentrate, lack of appetite, and repetitive thoughts. The client is reluctant to take the prescribed medications, fearing that they are harmful. After the nurse gives the client the medication, the nurse should take which of the following actions? 1. Instruct the client to open her mouth and move her tongue up and down and to each side while the nurse looks inside. 2. Ask the client if she has swallowed the medication completely. 3. Watch the client’s behavior to see if the medication is having its desired effect.