Nokea
The client has had a cataract removed. The nurse's discharge instructions should include which of the following?
- A. Keep the head aligned straight.
- B. Utilize bright lights in the home.
- C. Use an eye shield at night.
- D. Change the eye patch as needed.
Correct Answer: C
Rationale: Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.
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The client asks the nurse, 'Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?' On which of the following should the nurse base the response?
- A. The need to remove as much of the leg as possible.
- B. The adequacy of the blood supply to the tissues.
- C. The ease with which a prosthesis can be fitted.
- D. The client's ability to walk with a prosthesis.
Correct Answer: B
Rationale: The extent of amputation depends on tissue viability, determined by blood supply intraoperatively.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
Which of the following statements about nasoenteric tubes is correct?
- A. The tube cannot be attached to suction.
- B. The tube contains a soft rubber bag filled with mercury.
- C. The tube is taped securely to the client's cheek after insertion.
- D. The tube can have its placement determined only by auscultation.
Correct Answer: C
Rationale: Nasoenteric tubes are taped securely to the client's cheek to prevent dislodgement. They can be attached to suction, do not typically use mercury today, and placement is confirmed by methods like X-ray, not just auscultation. CN: Physiological adaptation; CL: Apply
During a home visit, a diabetic client begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.'
- B. We can teach your daughter to give the shots so you will not have to do it.'
- C. I can arrange to have a home care nurse give you the shots every day.'
- D. What is it about giving yourself the insulin shots that bothers you?'
Correct Answer: D
Rationale: Exploring the client's concerns about insulin injections promotes understanding and helps address fears, supporting adherence to treatment.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.