Nokea
A client tells the nurse his vision is blurred and hazy throughout the entire day. The nurse should recommend that the client do which of the following?
- A. Purchase a pair of magnifying glasses.
- B. Wear glasses with tinted lenses.
- C. Schedule an appointment with an optician.
- D. Schedule an appointment with an ophthalmologist.
Correct Answer: D
Rationale: An ophthalmologist is a physician who specializes in the treatment of disorders of the eye, and the nurse should advise the client to see a physician. An optician makes glasses, and it is not known at this point what the best treatment for the client is. Magnifying glasses or tinted lenses do not correct hazy or blurred vision.
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Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?
- A. Avoid showering for 48 hours after surgery.
- B. Return to work within 1 week.
- C. Leave dressings in place until you see the surgeon at the postoperative visit.
- D. Use acetaminophen (Tylenol) to control any fever.
Correct Answer: B
Rationale: Returning to work within 1 week (B) is reasonable for laparoscopic cholecystectomy, depending on recovery. Showering is typically allowed after 24-48 hours (A is incorrect). Dressings can often be removed sooner (C), and acetaminophen is for pain, not fever control (D).
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
- A. Limit fluid intake to 1,000 mL/day.
- B. Insert an indwelling urinary catheter.
- C. Establish a regular voiding schedule.
- D. Administer prophylactic antibiotics, as ordered.
Correct Answer: C
Rationale: A regular voiding schedule helps manage incontinence by promoting bladder emptying before urgency. Fluid restriction risks dehydration, indwelling catheters increase infection risk, and antibiotics are not preventive for incontinence.
While the nurse is providing preoperative teaching, the client says, 'I hate the idea of being an invalid after they cut off my leg.' The nurse's most therapeutic response should be:
- A. You'll still have one good leg to use.'
- B. Tell me more about how you're feeling.'
- C. Let's finish the preoperative teaching.'
- D. You're fortunate to have a wife who can take care of you.'
Correct Answer: B
Rationale: The therapeutic response, 'Tell me more about how you're feeling,' encourages the client to express fears and concerns, facilitating emotional support and coping. The other responses dismiss the client's feelings, prioritize teaching, or make assumptions, which are less therapeutic.
The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.