Nokea
After cataract removal surgery, the client is instructed to report sharp pain in the operative eye because this could indicate which of the following postoperative complications?
- A. Detached retina.
- B. Prolapse of the iris.
- C. Extracapsular erosion.
- D. Intraocular hemorrhage.
Correct Answer: D
Rationale: Sharp pain in the operative eye post-cataract surgery may indicate intraocular hemorrhage, which can increase intraocular pressure and cause severe pain, requiring immediate intervention.
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A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. Which action should be the nurse's first response?
- A. Assess for potential abuse.
- B. Check for diminished sensations.
- C. Document the findings.
- D. Clean and dress the area.
Correct Answer: B
Rationale: Macrocytic anemia, often due to vitamin B12 or folate deficiency, can cause peripheral neuropathy, leading to diminished sensations and increased risk of burns from prolonged heat exposure. The nurse's first action should be to check for sensory deficits to assess the underlying cause of the injury. Assessing for abuse, documenting, or dressing the wound are secondary actions.
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following?
- A. Induces sleep.
- B. Stimulates the client's appetite.
- C. Relieves muscular spasticity.
- D. Reduces the urine bacterial count.
Correct Answer: C
Rationale: Baclofen is a muscle relaxant used in MS to relieve spasticity, its primary therapeutic effect. It does not induce sleep, stimulate appetite, or reduce bacterial counts.
A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal to address for the client is:
- A. Fear of pain.
- B. Fear of further therapy.
- C. Feelings of isolation.
- D. Feelings of social inadequacy.
Correct Answer: A
Rationale: In hospice care for advanced Hodgkin's disease, the primary goal is to address fear of pain, ensuring comfort as death approaches. Fear of therapy, isolation, and social inadequacy are less relevant at this stage.
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply.
- A. If a client should develop crackles in their lung fields, it is a sign of a hemolytic reaction.
- B. Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals.
- C. Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure.
- D. It is important to ask the client about history of previous blood transfusions.
- E. Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion.
Correct Answer: A,E
Rationale: Crackles in the lung fields indicate transfusion-associated circulatory overload (TACO), not a hemolytic reaction, which typically presents with fever, chills, and hemoglobinuria. Pre-medication with diphenhydramine and acetaminophen is not always required, only when prescribed for clients with a history of allergic reactions. The other statements are correct: graft versus host disease is common in immunosuppressed clients, TACO is more likely in renal failure, and transfusion history is important.