Nokea
A cataract extraction is performed on a client's right eye. What is the priority nursing care immediately postoperative?
- A. Assist her to turn, cough, and deep breathe every two hours.
- B. Keep her NPO for four hours.
- C. Assist her in moving her arms and legs in ROM.
- D. Position client on her right side.
Correct Answer: C
Rationale: Assisting with range of motion prevents complications like stiffness while avoiding strain on the surgical eye.
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Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?
- A. Move the big toe up and down and ask in which direction the vibration is felt.
- B. Place a tuning fork on the big toe and ask if the vibrations are felt.
- C. Tap the client's cheek with the finger and determine if vibrations are felt.
- D. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.
Correct Answer: B
Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.
A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have?
- A. Severe eye pain
- B. Constant blurred vision
- C. Severe headaches, nausea, and vomiting
- D. Reports of seeing halos around objects
Correct Answer: D
Rationale: Open-angle glaucoma is characterized by halos around objects due to increased intraocular pressure, not severe pain or headaches.
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.
The nurse is providing teaching on the home treatment of acute sinusitis. Which interventions should the nurse advise the client to implement? Select all that apply.
- A. Take over-the-counter ranitidine.
- B. Apply warm compresses to the face.
- C. Use saline nasal spray as directed.
- D. Take over-the-counter pseudoephedrine.
- E. Spend time outdoors in the sunlight.
Correct Answer: B,C,D
Rationale: Applying warm compresses, using saline nasal spray, and taking a decongestant like pseudoephedrine relieve nasal and sinus congestion. Ranitidine treats dyspepsia, and sunlight exposure is unrelated to sinusitis.
The client comes to the emergency department after splashing chemicals into the eyes. Which intervention should the nurse implement first?
- A. Have the client move the eyes in all directions.
- B. Administer a broad-spectrum antibiotic.
- C. Irrigate the eyes with normal saline solution.
- D. Determine when the client had a tetanus shot.
Correct Answer: C
Rationale: Immediate irrigation with normal saline removes chemicals, preventing corneal damage. Eye movement, antibiotics, and tetanus history are secondary.