Nokea
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further instruction?
- A. I can use an ophthalmic analgesic ointment at night if I have eye discomfort.
- B. I do not need to be concerned about spreading this infection to others in my family.
- C. I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye.
- D. I should perform saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present.
Correct Answer: B
Rationale: Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime because discomfort becomes more noticeable when the eyelids are closed. When purulent discharge is present, saline eye irrigations or applications of warm compresses to the eye may be necessary before instilling the medication.
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The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.
A client is prescribed glipizide once daily. What intended effect of this medication should the nurse observe for?
- A. Weight loss
- B. Resolution of infection
- C. Decreased blood glucose
- D. Decreased blood pressure
Correct Answer: C
Rationale: Glipizide is an oral hypoglycemic agent that is taken in the morning. It is not used to enhance weight loss, treat infection, or decrease blood pressure.
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
- A. Dark cherry
- B. Clear as water
- C. Pale yellow or slightly pink
- D. Concentrated yellow with small clots
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
- A. I will be more careful to make sure that my father's needs are 100 \% met.
- B. I am so sorry and embarrassed that the abusive event occurred. It won't happen again.
- C. I feel better equipped to care for my father now that I know where to turn if I need assistance.
- D. Now that my father is going to move into my home with me, I will have to stop drinking alcohol.
Correct Answer: C
Rationale: Elder abuse is sometimes caused by family members who are being expected to care for their aging parents. This care can cause the family to become overextended, frustrated, or financially depleted. Knowing where to turn in the community for assistance with caring for an aging family member can bring much-needed relief. Using these alternatives is a positive coping skill for many families. The rest of the options are statements of good faith or promises, which may or may not be kept in the future.
A goal for a postpartum client states, 'The client will remain free of infection during her hospital stay.' Which assessment data would support that the goal has been met?
- A. Normal appetite
- B. Absence of fever
- C. Minimal vaginal bleeding
- D. Moderate breast tenderness
Correct Answer: B
Rationale: Fever is the first indication of an infection. Therefore, the absence of a fever indicates that an infection is not present. The remaining options are not associated with a postpartum infection.