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A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Slight rash.
- C. Worsening diarrhea.
- D. Fatigue.
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize
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After returning home, a client who has had cataract surgery will need to continue to instill eye drops in the affected eye. The client is instructed to apply slight pressure against the nose at the inner canthus of the eye after instilling the eyedrops. The rationale that supports applying pressure is that it:
- A. Prevents the medication from entering the tear duct.
- B. Prevents the drug from running down the client's face.
- C. Allows the sensitive cornea to adjust to the medication.
- D. Facilitates distribution of the medication over the eye surface.
Correct Answer: A
Rationale: Applying pressure at the inner canthus (punctal occlusion) prevents the medication from draining into the tear duct, which could lead to systemic absorption or reduced effectiveness of the eye drops.
The nurse should assess an older adult with macular degeneration for:
- A. Loss of central vision.
- B. Loss of peripheral vision.
- C. Total blindness.
- D. Blurring of vision.
Correct Answer: A
Rationale: Macular degeneration primarily affects the macula, leading to loss of central vision, which impairs activities like reading and recognizing faces.
The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet?
- A. Hamburger, salad, and milkshake.
- B. Baked liver, green beans, and coffee.
- C. Spaghetti with tomato sauce, salad, and coffee.
- D. Fried chicken, green beans, and skim milk.
Correct Answer: C
Rationale: Spaghetti with tomato sauce, salad, and coffee is low in cholesterol, unlike hamburger, liver, or fried chicken, which contain higher cholesterol or saturated fats.
A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
- A. Assessing the client's understanding of what the physician has explained.
- B. Describing the surgical procedure.
- C. Educating the client that the procedure will close the perforation and prevent recurrent infection.
- D. Informing the client that the procedure will improve hearing.
Correct Answer: A
Rationale: Assessing the client's current understanding allows the nurse to tailor education to the client's knowledge level and address specific concerns effectively.
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:
- A. Above the umbilicus.
- B. At the level of the xiphoid process.
- C. Over the victim's midabdominal area.
- D. Below the xiphoid process and above the umbilicus.
Correct Answer: D
Rationale: The Heimlich maneuver involves thrusts below the xiphoid process and above the umbilicus to safely dislodge a foreign body without injuring internal organs.