Nokea
A client is to be discharged following the removal of a cataract on the right eye. The nurse should tell the client to:
- A. Wear the metal eye shield only during waking hours.
- B. Report any eye pain to the doctor immediately.
- C. Refrain from using a pillow under his head.
- D. Avoid wearing dark glasses inside.
Correct Answer: B
Rationale: Reporting eye pain immediately is critical as it may indicate complications like infection or increased intraocular pressure. The eye shield is typically worn at night or as directed. Using a pillow is not contraindicated. Dark glasses are often recommended to reduce glare.
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Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: Left ventricular end-diastolic pressure. The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure, assessing the heart's ability to pump effectively.
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus
- A. 12 cm above the umbilicus
- B. at the level of the umbilicus
- C. just below the xiphoid process
- D. just above the symphysis pubis
Correct Answer: D
Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.
An adult is admitted to the emergency department following a fall. A piece of bone is protruding through the skin of the left thigh. In addition to assessing vital signs, what information is most essential to obtain from the client at this time?
- A. History of previous falls and fractures
- B. Date of last tetanus shot
- C. Type of environment where the fall took place
- D. Any previous surgeries
Correct Answer: B
Rationale: An open fracture (bone protruding) risks tetanus infection; knowing the last tetanus shot date is critical to determine prophylaxis need. Fall history, environment, or surgeries are secondary.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.