Nokea
During an ophthalmic assessment, which of the following is the nurse expected to observe carefully?
- A. Level of central vision
- B. Internal eye condition
- C. Pupil responses
- D. Rate of blinking
Correct Answer: C
Rationale: Pupil responses are critical in assessing neurological and ocular health. They provide important clues about potential disorders.
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A client returns to the Cardiovascular Intensive Care Unit following a coronary artery bypass graft (CABG). In planning the client's care, the most important electrolyte to monitor is:
- A. chloride.
- B. bicarbonate.
- C. potassium.
- D. sodium.
Correct Answer: C
Rationale: Chloride, bicarbonate, and sodium will need to be monitored, but they are not as important as potassium. Potassium will need to be closely monitored, because of its effects on the heart. Hypokalemia could result in supraventricular tachyarrhythmias.
Describe assessment data for the suicidal client.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
To evaluate a teaching plan implemented for a patient being discharged, what should the nurse do?
- A. Document the plan
- B. Report to the head nurse that teaching was done
- C. Compare learning outcomes with objectives
- D. Ask his family what he has learned
Correct Answer: C
Rationale: Comparing learning outcomes with objectives ensures the teaching plan was effective.
What is the physical environment of a surgery suite primarily designed to promote?
- A. Electrical safety
- B. Medical and surgical asepsis
- C. Comfort and privacy of the patient
- D. Communication among the surgical team
Correct Answer: B
Rationale: Maintaining a sterile environment is crucial to prevent infections and ensure patient safety.
A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct Answer: C
Rationale: Step 1: Checking the oximeter is essential to assess the client's oxygen saturation levels immediately post-procedure.
Step 2: Hypoxia can lead to serious complications, impacting the client's neurological status.
Step 3: The nurse must prioritize oxygenation status to prevent further brain injury or hypoxemia.
Step 4: Observing for CSF leaks, assessing temperature, and monitoring ICP are important but not as immediate as ensuring adequate oxygen supply.
Summary: Option C is correct as it addresses the most critical and immediate concern post-procedure, ensuring optimal oxygenation for the client's neurological recovery. Options A, B, and D are important but secondary to maintaining oxygen levels.