Nokea
The charge nurse observes a newly hired nurse caring for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which of the following interventions requires that the charge nurse intervene?
- A. The nurse leaves the eye shield in place.
- B. The nurse encourages the patient to cough.
- C. The nurse elevates the patient's head to 45 degrees.
- D. The nurse applies corticosteroid drops to the right eye.
Correct Answer: B
Rationale: Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.
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To decrease the risk for future hearing loss, which of the following actions should the nurse working with college students at the on-campus health clinic implement?
- A. Arrange to include otoscopic examinations for all patients.
- B. Administer rubella immunizations to all students at the clinic.
- C. Discuss the importance of limiting exposure to very high amplified music.
- D. Teach patients to regularly irrigate the ear to decrease cerumen impaction.
Correct Answer: C
Rationale: Exposure to high amplified music is a significant risk factor for hearing loss in young adults. Otoscopic exams and cerumen irrigation do not directly prevent hearing loss, and rubella immunization is unrelated to noise-induced hearing damage.
Which of the following topics should the nurse plan to include when teaching the patient with herpes simplex keratitis of the left eye about management of the infection?
- A. How to apply an occlusive dressing to the affected eye
- B. Need for frequent handwashing and avoiding touching the eyes
- C. Application of antibiotic drops to the left eye several times daily
- D. Use of corticosteroid ophthalmic ointment to decrease inflammation
Correct Answer: B
Rationale: The best way to avoid the spread of infection from one eye to another is to avoid rubbing or touching the eyes and to use careful handwashing when touching the eyes is unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a virus and antibiotic drops will not be prescribed. Topical corticosteroids typically are not ordered because they can contribute to a longer course of infection and more complications.
A patient with hearing loss asks the nurse about the use of a cochlear implant. Which of the following information will the nurse include when replying to the patient?
- A. Cochlear implants require training in order to receive the full benefit.
- B. Cochlear implants are not useful for patients with congenital deafness.
- C. Cochlear implants are most helpful as an early intervention for presbycusis.
- D. Cochlear implants improve hearing in patients with conductive hearing loss.
Correct Answer: A
Rationale: Extensive rehabilitation is required after cochlear implants in order for patients to receive the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be helpful for conductive loss. They are appropriate for some patients with congenital deafness.
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which of the following assessment data obtained by the nurse is of most concern?
- A. The patient has a temperature of 38.1°C (100.6°F).
- B. The patient reports mild ear pain.
- C. The patient has slight redness in the ear canal.
- D. The patient reports decreased hearing in the right ear.
Correct Answer: A
Rationale: A temperature of 38.1°C (100.6°F) after treatment for acute otitis media may indicate a persistent or worsening infection, requiring immediate attention. Mild ear pain, slight redness, and decreased hearing may be residual symptoms but are less concerning unless persistent or severe.
The nurse is caring for a patient with age-related macular degeneration who has just had photodynamic therapy. Which of the following statements by the patient indicates that the discharge teaching has been effective?
- A. I will need to use bright lights to read for at least the next week.
- B. I will use drops to keep my pupils dilated until my appointment.
- C. I will not use facial lotions near my eyes during the recovery period.
- D. I will keep covered with long-sleeve shirts and pants for the next 5 days.
Correct Answer: D
Rationale: The photosensitizing drug used for photodynamic therapy is activated by exposure to bright light and can cause burns in areas exposed to light for 5 days after the treatment. There are no restrictions on use of facial lotions, medications to keep the pupils dilated are not appropriate, and bright lights would increase the risk for damage caused by the treatment.