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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Nurse Betina should begin screening for lead poisoning when a child reaches which age?
- A. 6 months
- B. 12 months
- C. 18 months
- D. 24 months
Correct Answer: B
Rationale: Screening for lead poisoning typically begins at 12 months, as children at this age are more likely to be exposed to lead through crawling and hand-to-mouth activities.
A nurse assesses a client who is recovering from a myocardial infarction. The client’s pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
- A. Compare the results with previous pulmonary artery pressure readings.
- B. Increase the intravenous fluid rate because these readings are low.
- C. Immediately notify the health care provider of the elevated pressures.
- D. Document the finding in the client’s chart as the only action.
Correct Answer: A
Rationale: Comparing the current pulmonary artery pressure readings with previous ones helps determine if the values are stable or changing, which guides further intervention.
Of the following, the cardiac lesion resulting in increased volume load is
- A. valvular pulmonic stenosis
- B. patent ductus arteriosus
- C. valvular aortic stenosis
- D. mitral stenosis
Correct Answer: B
Rationale: Patent ductus arteriosus leads to increased volume load on the left side of the heart.
All are true about TAPSE (Tricuspid Annular Plane Systolic Excursion), except
- A. Normal TAPSE is >17 mm
- B. Reliable measure of RV systolic function
- C. Can be measured using either M-mode or 2D echo
- D. TAPSE is measured at septal aspect of tricuspid annulus
Correct Answer: D
Rationale: TAPSE is measured at the lateral aspect of the tricuspid annulus, not the septal aspect.
Pulmonary hypertension is a complication of:
- A. ASD
- B. Eisenmenger syndrome
- C. Tricuspid atresia
- D. Tricuspid regurgitation
Correct Answer: B
Rationale: Eisenmenger syndrome is a well-known cause of pulmonary hypertension. The other options (a-d) can also lead to pulmonary hypertension but are less specific.
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