Nokea
A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply.
- A. Images will appear to be one-third larger.
- B. Look through the center of the glasses.
- C. Use handrails when climbing stairs.
- D. Stay out of the sun for 2 weeks.
Correct Answer: A,B,C
Rationale: The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Staying out of the sun is not necessary, but dark glasses may be used to prevent photophobia.
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Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
- A. Limit caffeine intake to two cups of coffee per day.
- B. Do not lie down for 2 hours after eating.
- C. Follow a low-protein diet.
- D. Take medications with milk to decrease irritation.
Correct Answer: B
Rationale: Avoiding lying down for 2 hours after eating prevents reflux of stomach contents into the esophagus, a key strategy for managing GERD. The other options are incorrect or exacerbate symptoms.
The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home?
- A. A 4-year-old cocker spaniel.
- B. Scatter rugs.
- C. Snack tables.
- D. Rocking chairs.
Correct Answer: B
Rationale: Scatter rugs are a significant fall risk due to tripping hazards.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
- A. 1
- B. 2
- C. 3
- D. 4
- E. 5
Correct Answer: A
Rationale: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
An appropriate nursing intervention for a client with fatigue related to cancer treatment includes teaching the client to:
- A. Increase fluid intake.
- B. Minimize naps or periods of rest during day.
- C. Conserve energy by limiting activities.
- D. Limit dietary intake of high-fiber foods.
Correct Answer: C
Rationale: Conserving energy by limiting activities helps manage fatigue, a common side effect of cancer treatment, by balancing rest and activity.