Nokea
A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
- A. Report reoccurring visual signs of retinal detachment.
- B. Maintain the head in one postoperative position.
- C. Watch for signs of infection in the surgical eye.
- D. Ambulate to the bathroom with assistance.
Correct Answer: A
Rationale: Reporting signs of retinal detachment is critical to ensure the success of the scleral buckling procedure.
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After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.
An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?
- A. What time of day the multivitamin is taken.
- B. The amount of calcium in the multivitamin.
- C. Usual activity after taking the multivitamin.
- D. If the multivitamin is taken with a meal or snack
Correct Answer: B
Rationale: Confirming calcium content in the multivitamin ensures adequate intake for bone health, critical for osteoporosis prevention.
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
- A. Fatigue.
- B. Pain when eating.
- C. Nausea.
- D. Altered taste sensation.
Correct Answer: B
Rationale: Severe facial pain from trigeminal neuralgia deters eating, leading to imbalanced nutrition.
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
- A. Neutrophil count.
- B. C-reactive protein level.
- C. Platelet count.
- D. Serum potassium and sodium levels.
Correct Answer: B
Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.
The nurse includes the problem of 'Risk for infection' in the plan of care for a client with myelosuppression. Which laboratory value of care provides the greatest support for this nursing problem?
- A. Hematocrit of 33% (0.33 volume fraction).
- B. White blood cell count of 1,500/mm3 (1.5 x 10°)
- C. Hemoglobin of 10 g/dl (6.21 mmol/L)
- D. Red blood cell count of 3.5 x 10l(3.5 x 10°).
Correct Answer: B
Rationale: A low white blood cell count (1,500/mm³) indicates leukopenia, increasing infection risk, unlike other values.