Nokea
After cataract surgery, the client tells the nurse of severe pain in the operative eye. Which nursing action is most appropriate?
- A. Report the finding to the charge nurse.
- B. Give the client a prescribed analgesic.
- C. Assess the client's pupil response with a penlight.
- D. Reposition the client on the operative side.
Correct Answer: A
Rationale: Severe pain may indicate complications, requiring immediate reporting to the charge nurse.
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Before the client's arrival, which services should the nurse anticipate will facilitate this client's recovery? Select all that apply.
- A. Nutritional consult
- B. Nutritional therapy
- C. Enterostomal therapy
- D. Psychiatric therapy
- E. Physician consult
- F. Occupational therapy
Correct Answer: A,B,C,E,F
Rationale: These services address nutrition, wound care, medical oversight, and functional recovery.
The nurse knows that the client who underwent a stapedectomy understands the discharge instructions when the client identifies which activity to avoid for the next 6 months?
- A. Listening to music
- B. Flying in an airplane
- C. Driving an automobile
- D. Singing in the choir
Correct Answer: B
Rationale: Pressure changes during flying can disrupt healing after a stapedectomy.
The nurse is preparing the plan of care for a client diagnosed with psoriasis. Which intervention should the nurse include in the plan of care?
- A. Apply a thin dusting with Mycostatin, an antifungal powder, over the area.
- B. Cover the area with an occlusive dressing after applying a steroid cream.
- C. Administer acyclovir, an antiviral medication, to the affected areas six (6) times a day.
- D. Teach the client the risks and hazards of implanted radiation therapy.
Correct Answer: B
Rationale: Occlusive dressings with steroids enhance absorption, treating psoriasis. Mycostatin is for fungal infections, acyclovir is for viral infections, and radiation is irrelevant.
Which of the following would be the most appropriate action for the nurse to take when applying eye patches to the client?
- A. Occluding all sources of room light
- B. Ensuring that both patches exert tight pressure on the eyes
- C. Maintaining the client's eyelids in a closed position
- D. Making sure the client can see while the patches are in place
Correct Answer: C
Rationale: Keeping eyelids closed under patches prevents movement and further retinal damage.
The client is being admitted to the ED after a house fire. Place the client's problems in the order of priority in which they should be addressed by the nurse.
- A. Has 48% partial- and full-thickness burn injury
- B. Laceration on the face that has stopped bleeding
- C. Inhalation injury from smoke
- D. History of hypertension
Correct Answer: C,A,B,D
Rationale: Inhalation injury from smoke is the priority problem that should be addressed first to ensure that the client has a patent airway. The 48% partial- and full-thickness burn injury should be addressed next due to fluid loss and pain. The laceration on the face that has stopped bleeding should be addressed next, possibly requiring suturing. History of hypertension can be addressed last, as fluid shifts from the burn are likely to lower BP.