Nokea
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Sleep on the abdomen to facilitate wound healing.
- B. Bend at the waist to pick objects up from the floor.
- C. Notify the surgeon if white drainage develops on the eyelids.
- D. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
Correct Answer: D
Rationale: Lifting heavy objects can increase intraocular pressure, disrupting healing post-cataract surgery. Avoiding heavy lifting is critical. Other options risk complications or are unnecessary.
You may also like to solve these questions
A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?
- A. Hemoglobin level
- B. Fluid intake
- C. Temperature
- D. Skin color
Correct Answer: C
Rationale: A baseline temperature is crucial to monitor for febrile reactions during transfusion. A significant rise indicates a reaction requiring intervention. Other data are less immediate.
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?
- A. To place my leg under a heat lamp every 3 hours
- B. Keep a heating pad on the calf of my right leg when I am lying down.
- C. wrap a warm, wet towel around my right calf every 4 hours.
- D. will sit on the side of the tub and soak my right leg two times every day.
Correct Answer: C
Rationale: A warm, wet towel provides moist heat, promoting blood flow and healing in cellulitis without risking burns or uneven heating from other methods.
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Pain medication administration
- B. Poor nutritional state
- C. wound infection
- D. Obesity
- E. Altered mental status
Correct Answer: B,C,D
Rationale: Poor nutrition weakens tissue strength, infection compromises wound integrity, and obesity increases pressure on the wound, all raising dehiscence risk. Pain medication and altered mental status do not directly contribute.
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.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. increased heart rate
- B. Increase hematocrit
- C. increased blood pressure
- D. Increased temperature
- E. increased respiratory rate
Correct Answer: A,C,E
Rationale: Tachycardia occurs as the heart compensates for increased blood volume. Hypertension results from increased vascular resistance due to excess fluid. Increased respiratory rate is due to pulmonary congestion from fluid overload. Hematocrit decreases due to dilution, and temperature is not directly affected.