Nokea
A nurse is caring for a client who has Meniere's disease. The nurse identifies which of the following manifestations is caused by an excessive accumulation of endolymph fluid?
- A. Myopia
- B. Vertigo
- C. Photophobia
- D. Presbycusis
Correct Answer: B
Rationale: Vertigo is a primary symptom of Meniere's disease, caused by excessive endolymph fluid in the inner ear affecting balance and spatial orientation. Myopia, photophobia, and presbycusis are unrelated to endolymph accumulation.
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A nurse is caring for a postoperative client following abdominal surgery. Which of the following findings should cause the nurse to anticipate the client might be experiencing a hemorrhage?
- A. Hypotension
- B. Diaphoresis
- C. Bradycardia
- D. Diarrhea
Correct Answer: A
Rationale: Hypotension and tachypnea are signs of hemorrhage due to decreased blood volume and compensatory increased respiratory rate. Diaphoresis may occur but is less specific, while bradycardia and diarrhea are not typical.
A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify which of the following persons is qualified?
- A. Phlebotomist
- B. Assistive personnel
- C. Senior nursing student
- D. Oncology nurse
Correct Answer: D
Rationale: An oncology nurse is a registered nurse with specialized training and experience in administering blood products, making them qualified to double-check blood labels and patient identification. Phlebotomists, assistive personnel, and senior nursing students lack the required training or authority for this critical safety task.
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 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.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
- A. Keep family members aware of his condition.
- B. Talk with the client during wound care.
- C. Rotate nursing staff so he can have varied interactions.
- D. Assign assistive personnel to keep his room neat and clean.
Correct Answer: B
Rationale: Talking with the client during wound care builds trust, provides emotional support, and helps cope with pain and stress. Other options are less directly supportive emotionally.