Nokea
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
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A nurse is assessing a client with Addison's disease. The nurse should review laboratory reports for which of the following?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Decreased blood urea nitrogen (BUN) level.
Correct Answer: C
Rationale: Hypoglycemia is common in Addison's disease due to cortisol deficiency, which impairs gluconeogenesis.
A 75-year-old male client has a history of macular degeneration. While he is in the hospital, the priority nursing goal will be:
- A. To provide education regarding community services for clients with adult macular degeneration (AMD).
- B. To provide health care related to monitoring his eye condition.
- C. To promote a safe, effective care environment.
- D. To improve vision.
Correct Answer: C
Rationale: Promoting a safe, effective care environment is the priority to prevent falls and injuries due to impaired central vision in a hospital setting.
The nurse is performing discharge education to an older adult diagnosed with cataracts. Which of the following statements indicates effective understanding?
- A. I may have to quit driving until I get the cataracts treated.'
- B. I should spend less time outdoors in the sun and plan more activities at night.'
- C. I will need to avoid activities that raise my intraocular pressure, such as bending at the waist.'
- D. I will have to be careful since my eyes won't move together.'
Correct Answer: A
Rationale: Cataracts can impair vision, making driving unsafe until treated. Sun exposure does not directly affect cataracts, intraocular pressure is not a primary concern, and eye movement misalignment is not typical.
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to:
- A. Decreased blood flow
- B. Increased blood flow
- C. Increased blood viscosity
- D. Increased blood viscosity
Correct Answer: A
Rationale: In PVD, decreased blood flow to the extremities limits oxygen delivery to muscles, reducing exercise tolerance. In heart failure, reduced cardiac output further exacerbates this limitation, as the heart cannot meet increased oxygen demands during activity. Increased blood flow or viscosity is not relevant, and the options are repeated incorrectly in the document.