Nokea
A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?
- A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
- B. Wear sunglasses when outdoors to prevent photophobia.
- C. Apply cold compresses to reduce inflammation.
- D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.
Correct Answer: D
Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.
You may also like to solve these questions
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which laboratory value should be closely monitored?
- A. Serum creatinine of 2.0 mg/dL
- B. Serum sodium of 135 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Blood glucose of 150 mg/dL
Correct Answer: C
Rationale: A serum potassium level of 5.5 mEq/L should be closely monitored in a client with chronic heart failure as it may indicate hyperkalemia, requiring intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias in patients with heart failure. Serum creatinine (Choice A) is important to monitor for kidney function but is not the priority in this case. Serum sodium (Choice B) and blood glucose (Choice D) levels are not typically the primary focus when assessing a client with heart failure presenting with respiratory symptoms and crackles in the lungs.
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Ineffective coping related to denial.
- B. Risk for impaired cardiac function.
- C. Noncompliance related to lack of knowledge.
- D. Anxiety related to hospitalization.
Correct Answer: A
Rationale: The correct answer is A: Ineffective coping related to denial. The client's desire to leave the hospital shortly after a myocardial infarction despite the severity of the condition indicates denial and ineffective coping. This behavior could lead to complications as the client may not adequately address his health needs. Choice B, Risk for impaired cardiac function, is not the most appropriate nursing problem in this scenario as the client's behavior is more indicative of psychological coping issues rather than a direct physiological risk at this moment. Choice C, Noncompliance related to lack of knowledge, does not align with the client's behavior of wanting to leave the hospital. Choice D, Anxiety related to hospitalization, may not be the best option as the client's behavior is more suggestive of denial rather than anxiety about being hospitalized.
A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be reported to the healthcare provider before the procedure?
- A. Serum creatinine of 2.5 mg/dL
- B. Serum potassium of 6.5 mEq/L
- C. Serum calcium of 8 mg/dL
- D. Serum bicarbonate of 24 mEq/L
Correct Answer: B
Rationale: The correct answer is B. A serum potassium level of 6.5 mEq/L is dangerously high and should be reported before hemodialysis to prevent cardiac complications. High potassium levels can lead to life-threatening arrhythmias. Serum creatinine (Choice A) is elevated in renal dysfunction but not the most critical value to report before hemodialysis. Serum calcium (Choice C) and serum bicarbonate (Choice D) levels are within normal limits and are not immediate concerns before hemodialysis.
A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which intervention should the nurse implement first?
- A. Administer intravenous fluids.
- B. Monitor the client's urine output.
- C. Obtain a blood glucose level.
- D. Administer 50% dextrose IV push.
Correct Answer: D
Rationale: The correct answer is to administer 50% dextrose IV push first. In hyperglycemic hyperosmolar syndrome, the main goal is to rapidly reduce blood glucose levels to prevent further complications. Administering dextrose intravenously can help reverse the effects of high blood glucose levels quickly. Administering intravenous fluids, monitoring urine output, and obtaining a blood glucose level are important interventions but are not the first priority in treating HHS. Administering 50% dextrose IV push takes precedence as it directly addresses the elevated blood glucose levels.
The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?
- A. Encourage the UAP to remain in the client's room until the procedure is completed.
- B. Explain that the hand rub can be completed in less than 2 minutes.
- C. Inform the UAP that handwashing helps to promote better asepsis.
- D. Determine why the UAP was not wearing gloves in the client's room.
Correct Answer: B
Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.