An older 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. Teach a family member to administer eye drops
- B. Encourage deep breathing and coughing exercises
- 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 protects the surgical site from accidental trauma during sleep, which is critical for postoperative healing.
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Initial tests in a 2-year-old child with failure to thrive include:
- A. Thyroid function tests
- B. Sweat test
- C. Urine culture
- D. Colonoscopy
Correct Answer: B
Rationale: a sweat test is crucial for diagnosing cystic fibrosis, a common cause of failure to thrive in children. The other tests (a-d) are less specific and not typically first-line for this presentation.
Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?
- A. Iron-rich formula and baby food
- B. Whole milk and baby food
- C. Skim milk and baby food
- D. Iron-rich formula only
Correct Answer: A
Rationale: Iron-rich formula and baby food provide essential nutrients for a 5-month-old infant transitioning from breastfeeding.
Blueberry muffin' lesions seen in rubella is due to
- A. Dermal erythropoiesis
- B. Thrombocytopenia
- C. Ecchymosis
- D. Vasculitis
Correct Answer: A
Rationale: Blueberry muffin' lesions in congenital rubella are due to dermal erythropoiesis, where extramedullary hematopoiesis occurs in the skin.
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)
- A. 0.9
- B. 1
- C. 9
Correct Answer: A
Rationale: The calculation is based on the prescribed dose and the concentration of the medication.
Toxoplasma gondii infection in humans causes:
- A. Oral ulcers
- B. Cervical lymphadenopathy
- C. Microcephaly
- D. Chorioretinitis
Correct Answer: D
Rationale: Chorioretinitis is a hallmark of congenital toxoplasmosis, leading to vision impairment.