Nokea
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Encourage deep breathing and coughing exercises.
- B. Teach a family member to administer eye drops.
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization.
Correct Answer: C
Rationale: An eye shield is crucial to protect the operated eye from accidental injury during sleep, preventing rubbing and potential complications. Deep breathing and coughing can increase intraocular pressure, teaching medication administration is not an immediate priority, and frequent vital sign monitoring is excessive for cataract surgery.
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An adult female client, who is an office worker, comes to the occupational health dinic with an edematous right leg twice the size of the left leg. The client reports that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. Which initial nursing action should the occupational health nurse take?
- A. Ask the client to rate her pain on a scale from 0 to 10.
- B. Teach the client to keep the leg elevated
- C. Treat with ice then apply an elastic bandage wrap.
- D. Check the leg for warmth and erythema.
Correct Answer: D
Rationale: Checking for warmth and erythema assesses for deep vein thrombosis, a serious condition indicated by unilateral leg swelling.
A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?
- A. Place an indwelling urinary catheter and attach a bedside drainage unit.
- B. Send the client to x-ray for a flat plate of the abdomen.
- C. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- D. Give a prescribed analgesic for temperature above 101° F (38.3°C).
Correct Answer: C
Rationale: An NGT decompresses the stomach, addressing potential bowel obstruction indicated by vomiting and hyperactive bowel sounds.
A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
- A. Insert an indwelling urinary catheter.
- B. Obtain blood for serum cardiac enzymes.
- C. Provide emotional support.
- D. Auscultate lung fields for fine rales.
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?
- A. Palpate all peripheral pulses in the extremities.
- B. Encourage cough and deep breathing exercises.
- C. Complete a focused assessment of the abdomen.
- D. Initiate measurement of fluid intake and output.
Correct Answer: C
Rationale: A focused abdominal assessment determines the severity of bleeding and guides further interventions, prioritizing over pulses, respiratory exercises, or fluid monitoring.
After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.