Nokea
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?
- A. "I need something for the pain in my eye. I can't stand it."
- B. "It's hard to see with a patch on one eye. I'm afraid of falling"
- C. "My eye really itches, but I'm trying not to rub it."
- D. "The bright light in this room is really bothering me."
Correct Answer: A
Rationale: Severe pain after cataract surgery is unusual and could indicate complications like increased intraocular pressure or infection, requiring immediate reporting. Other comments reflect common post-surgical experiences.
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A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
- A. The first 2 min
- B. The final 2 min
- C. The final 15 min
- D. The first 15 min
Correct Answer: D
Rationale: Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for signs of a reaction, such as fever, chills, rash, or difficulty breathing.
A nurse is teaching a group of clients about lifestyle modifications that could decrease risk factors for developing hearing loss. Which of the following risk factors should the nurse include in the teaching?
- A. Consume foods high in potassium
- B. Avoid smoking tobacco products
- C. increase oral intake of water
- D. Limit alcohol to two drinks daily
Correct Answer: B
Rationale: Smoking impairs blood flow to the cochlea and auditory nerve, increasing hearing loss risk. Potassium, hydration, and moderate alcohol are not directly linked to hearing loss prevention.
In reviewing a patient's complete blood count (CBC) results, the nurse notes a 'shift to the left.' What is the significance of these results?
- A. There is an elevated number of immature thrombocytes.
- B. There is an elevated number of immature neutrophils (bands),
- C. There is an elevated number of mature neutrophils (segs)
- D. There is an elevated number of mature erythrocytes
Correct Answer: B
Rationale: A 'shift to the left' indicates an increase in immature neutrophils (bands), often signaling acute infection or inflammation as the body releases more neutrophils to fight pathogens.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
- A. Heart rate
- B. Weight
- C. Urine output
- D. BP
Correct Answer: A
Rationale: A decrease in heart rate indicates improved cardiac output and reduced tachycardia, suggesting adequate fluid replacement. Weight may increase, urine output should increase, and BP stabilizes but is less direct an indicator.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?
- A. Packed RBCS
- B. Fresh frozen plasma
- C. Recombinant
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Recombinant factor VIII is a synthetic form of the clotting factor deficient in hemophilia A, used to increase factor VIII levels before procedures to prevent excessive bleeding. Packed RBCs treat anemia, not clotting deficiencies. Fresh frozen plasma contains all clotting factors but is less targeted than recombinant factor VIII. Prophylactic antibiotics prevent infection, not bleeding.