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Questions 164

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Question 1 of 5

A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?

Correct Answer: B

Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.

Question 2 of 5

The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order. All options must be used.

Order the Items

Source Container

Exhale completely
Deliver one puff of medication into spacer
Place lips tightly around the mouth piece
Rinse mouth with water
Shake the inhaler and attach it to spacer
Take a slow deep breath, and hold it for 10 seconds

Correct Answer: E,A,B,C,F,D

Rationale: The correct order is: 1) Shake the inhaler and attach it to spacer (prepares medication); 2) Exhale completely (clears lungs); 3) Deliver one puff into spacer (releases medication); 4) Place lips tightly around the mouthpiece (ensures delivery); 5) Take a slow deep breath, and hold it for 10 seconds (allows medication absorption); 6) Rinse mouth with water (prevents oral thrush).

Question 3 of 5

A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?

Correct Answer: B

Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.

Question 4 of 5

A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:

Correct Answer: A

Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.

Question 5 of 5

The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.

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