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A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Take a warm shower every day.
- C. Resume regular activities immediately.
- D. Avoid all physical activity for the next month.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This instruction is crucial after a cataract extraction to prevent any strain on the eye during the initial healing period. Lifting heavy objects can increase intraocular pressure and potentially lead to complications. Choice B (Take a warm shower every day) is not directly related to post-operative care for a cataract extraction. Choice C (Resume regular activities immediately) is incorrect as the client should avoid strenuous activities, including heavy lifting, to allow proper healing. Choice D (Avoid all physical activity for the next month) is overly restrictive and unnecessary. It's important to provide specific, clear, and relevant instructions to support the client's recovery.
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A nurse works with an AP assigned to bathe a client with herpes zoster. The AP asks if it is contagious. What should the nurse say?
- A. Herpes zoster is not contagious to people who have had chickenpox.
- B. Herpes zoster spreads through the air.
- C. Herpes zoster is highly contagious to everyone.
- D. Herpes zoster only spreads through blood contact.
Correct Answer: A
Rationale: The correct answer is A. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Individuals who have had chickenpox in the past are not at risk of getting shingles from someone with herpes zoster. The virus is not transmitted through the air (choice B) or through blood contact only (choice D). It is not highly contagious to everyone (choice C). By explaining to the AP that herpes zoster is not contagious to individuals who have had chickenpox, the nurse provides accurate information and helps alleviate concerns about the spread of the virus.
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
- A. Fine crackles in the lungs
- B. Increased anteroposterior diameter of the chest
- C. Increased tactile fremitus
- D. Fever and chills
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD with emphysema, there is air trapping leading to hyperinflation of the lungs, causing the chest to expand more in the front-to-back direction (increased anteroposterior diameter). This is known as barrel chest.
A: Fine crackles are not typically associated with COPD/emphysema, they are more common in conditions like heart failure or pneumonia.
C: Increased tactile fremitus is not typically seen in COPD/emphysema, it may be present in conditions like pneumonia.
D: Fever and chills are not typical findings in COPD/emphysema unless there is an infection present.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has a wound infection and is on antibiotics.
- B. The client who has gastroenteritis and is febrile.
- C. The client who is receiving IV fluids and is in pain.
- D. The client who is on a clear liquid diet and has hypokalemia.
Correct Answer: B
Rationale: The correct answer is B. The client with gastroenteritis and fever is at risk for fluid volume deficit due to increased fluid loss from vomiting and diarrhea. Fever also increases fluid loss through perspiration. The other choices do not directly indicate increased fluid loss. A: Antibiotics for wound infection may not directly lead to fluid volume deficit. C: IV fluids would help maintain hydration status, so this client is not at risk for deficit. D: Hypokalemia may be related to electrolyte imbalance, but not necessarily fluid volume deficit.
A female middle adult client tells a nurse that she tested positive for a mutant BRCA1 gene. The nurse should recognize that the client is at an increased risk for which of the following situations?
- A. Developing breast cancer
- B. Developing ovarian cancer
- C. Developing uterine cancer
- D. Developing cervical cancer
Correct Answer: A
Rationale: The correct answer is A: Developing breast cancer. The BRCA1 gene mutation is associated with an increased risk of breast cancer in women. The mutation affects the body's ability to repair damaged DNA, leading to a higher likelihood of developing breast cancer. This risk is significantly higher in women with the mutant BRCA1 gene compared to those without it. Choices B, C, and D are incorrect because the BRCA1 gene mutation is not specifically linked to an increased risk of ovarian, uterine, or cervical cancer. Therefore, the client should be counseled and monitored closely for early detection and prevention of breast cancer.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?
- A. Hemoglobin of 12 g/dL
- B. Platelet count of 350,000/mm3
- C. CD4-T-cell count 180 cells/mm3
- D. White blood cell count of 10,000/mm3
Correct Answer: C
Rationale: The correct answer is C: CD4-T-cell count 180 cells/mm3. In HIV care, monitoring the CD4-T-cell count is crucial as it reflects the immune system's ability to fight infections. A low CD4 count indicates a weakened immune system, increasing the client's susceptibility to opportunistic infections. This value guides treatment decisions, such as initiating antiretroviral therapy. The other options, while important, do not directly reflect the client's immune status in the context of HIV. Hemoglobin and platelet counts are relevant for assessing anemia and clotting function, respectively. White blood cell count is a general indicator of infection or inflammation. Prioritizing CD4-T-cell count ensures appropriate management of HIV and prevention of complications.