Nokea
A client with glaucoma is to receive 3 gtt of acetazolamide (Diamox) in the left eye. What should the nurse do?
- A. Ask the client to close his right eye while administering the drug in the left eye.
- B. Have the client look up while the nurse administers the eyedrops.
- C. Have the client lift his eyebrows while the nurse positions the hand with the dropper on the client's forehead.
- D. Wipe the eyes with a tissue following administration of the drops.
Correct Answer: B
Rationale: Having the client look up while administering eyedrops ensures the drops are placed in the lower conjunctival sac, minimizing discomfort and maximizing absorption.
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Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications?
- A. Weight lifting.
- B. Walking.
- C. Aquatic exercise.
- D. Tai chi exercise.
Correct Answer: C
Rationale: Aquatic exercise reduces joint stress while promoting weight loss, ideal for osteoarthritis.
A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply.
- A. Administer all ordered oral medications.
- B. Check for iodine sensitivity.
- C. Verify that written consent has been obtained.
- D. Withhold food and oral fluids before the procedure.
- E. Insert a urinary drainage catheter.
Correct Answer: B,C,D
Rationale: Checking iodine sensitivity (B), verifying consent (C), and withholding food/fluids (D) are standard pre-catheterization tasks to ensure safety and preparedness.
A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply.
- A. Aerobic activity
- B. Strength training
- C. Weight control
- D. Stress management
Correct Answer: A,C,D
Rationale: Rationales: A) Aerobic activity (e.g., walking) improves circulation and reduces clot recurrence. C) Weight control decreases venous pressure and clot risk. D) Stress management reduces sympathetic activation, aiding vascular health. B) Strength training is less critical for clot management and may be contraindicated initially.
Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?
- A. Incorporate physical exercise as tolerated into the daily routine.
- B. Monitor peak flow numbers after meals and at bedtime.
- C. Eliminate stressors in the work and home environment.
- D. Use sedatives to ensure uninterrupted sleep at night.
Correct Answer: A
Rationale: Regular exercise, as tolerated, improves lung function and overall health in asthma. Peak flow monitoring is typically done morning and evening. Eliminating all stressors is unrealistic. Sedatives may depress respiration and are not recommended.