Nokea
A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.
You may also like to solve these questions
A client experiencing hallucinations.
Which of the following behaviors by a client should the nurse record to indicate that the client is experiencing hallucinations?
- A. The client sits immobilized for long periods of time.
- B. The client turns and tilts his head as if talking to someone.
- C. The client expresses the belief that the physician is out to get him.
- D. The client wrings his hands and paces constantly.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct-hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
Which assessment is most essential before administering digoxin to an adult?
- A. Ask the client if he has chest pain.
- B. Take an apical pulse.
- C. Take the client's blood pressure.
- D. Ask the client if he is short of breath.
Correct Answer: B
Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.
The nurse is caring for a client receiving chemotherapy who is experiencing neutropenia. Which intervention would be most appropriate to recommend for inclusion in the client's plan of care?
- A. Assess the client's temperature every 4 hours due to risk of hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct the client in the use of a soft toothbrush.
- D. Assess the client for hematuria.
Correct Answer: B
Rationale: Neutropenia increases the risk of infection due to low neutrophil counts. Avoiding large crowds and sick individuals minimizes exposure to pathogens, making B the most appropriate intervention. Answer A is incorrect as hypothermia is not a primary concern. Answer C, while relevant for preventing mucosal bleeding, is less critical than infection prevention. Answer D is unrelated to neutropenia.