Nokea
A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to:
- A. Reduce rapid eye movements.
- B. Decrease the irritation caused by light entering the damaged eye.
- C. Protect the injured eye from infection.
- D. Rest the eyes to promote healing.
Correct Answer: A
Rationale: Patching both eyes reduces rapid eye movements, which could worsen retinal detachment by preventing further stress on the retina.
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The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
An African-American woman had experienced severe palpitations, weakness, and shortness of breath after taking bacitracin (Bactrim). As a part of the discharge planning, the nurse should evaluate the client's knowledge about:
- A. Increased folic acid needs.
- B. Congenital enzyme deficiency.
- C. Restricted activity in hot weather.
- D. Need for blood transfusions.
Correct Answer: B
Rationale: Bactrim (sulfamethoxazole/trimethoprim) can cause hemolytic anemia in individuals with glucose-6-phosphate dehydrogenase (G6PD) deficiency, a congenital enzyme deficiency common in African-American populations. The nurse should assess the client's understanding of G6PD deficiency and how to avoid triggers like certain medications. Folic acid, activity restrictions, and transfusions are not directly related.
Vasopressin (Pitressin) is administered to the client with diabetes insipidus because it:
- A. Decreases blood pressure.
- B. Increases tubular reabsorption of water.
- C. Increases release of insulin from the pancreas.
- D. Decreases glucose production within the liver.
Correct Answer: B
Rationale: Vasopressin increases water reabsorption in the kidneys, reducing urine output in diabetes insipidus.
What should the nurse assess first in a client with a recent head injury?
- A. Pupil response.
- B. Blood pressure.
- C. Pain level.
- D. Reflexes.
Correct Answer: A
Rationale: Pupil response is assessed first to detect neurological changes, such as increased intracranial pressure, in a head injury.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?
- A. A 55-year-old client who is 6 feet tall and weighs 180 lb.
- B. A 75-year-old who lives alone.
- C. A 74-year-old who has periodontal disease with periodontitis.
- D. A 75-year-old who has asthma and uses an inhaler.
Correct Answer: C
Rationale: Periodontal disease increases infection risk due to potential bacterial spread to the prosthesis.