Nokea
The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?
- A. Auscultate breath sounds to assess for crackles
- B. Monitor for >50 mL/hr urine output
- C. Monitor Glasgow Coma Scale increasing from 8/15 to 9/15
- D. Press over the tibia to assess for pitting edema
Correct Answer: D
Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.
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The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia?
- A. 29-year-old client with new-onset influenza
- B. 40-year-old client who is a cyclist and is training for an upcoming race
- C. 65-year-old client with cellulitis of the right leg
- D. 72-year-old client with emphysema who is receiving prednisone
Correct Answer: D
Rationale: Prednisone increases blood glucose, but abrupt cessation or dose changes can cause hypoglycemia in type 1 diabetes due to insulin sensitivity. Influenza, exercise, and cellulitis pose risks, but prednisone’s metabolic impact is greatest.
The nurse has taught the parent of a 6-year-old client with bacterial conjunctivitis how to administer ophthalmic medications. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. My child should look down at the floor while I administer the eye drops.
- B. My child should squeeze the eyes closed after I administer the eye drops.
- C. I will apply firm pressure to my child's eyes after I administer the eye ointment
- D. I will apply the eye ointment along my child's lower eyelids starting at the inner corner of the eyes
Correct Answer: D
Rationale: Appropriate administration of ophthalmic medications (eg, eye drops, ointments) protects eye structures and ensures appropriate distribution across the eye. Ophthalmic ointment should be administered along the lower eyelid, moving from the inner canthus to the outer canthus (inner corner to outer corner) (Option 4). In addition, the medication package (eg, eye dropper, tube of ointment) must not touch the eyes to prevent contamination.
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?
- A. Avoid strenuous activity before the surgery
- B. Continue to exercise, even if angina occurs. It will strengthen your heart muscles
- C. Take short walks 3 times a day
- D. There are no activity restrictions unless angina occurs
Correct Answer: A
Rationale: Strenuous activity risks syncope or ischemia in aortic stenosis, so avoidance is critical. Exercise despite angina is dangerous, short walks may still trigger symptoms, and no restrictions ignore risks.
The nurse is caring for an 8-month-old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Frequent pulling on the affected ear
- B. Purulent drainage from the affected ear
- C. Refusal to eat
- D. Restlessness and irritability
- E. Retracted tympanic membranes
Correct Answer: A,C,D
Rationale: Ear pulling, refusal to eat, and irritability are common in otitis media due to pain and inflammation. Purulent drainage is less common unless the eardrum ruptures, and tympanic membranes are typically bulging, not retracted.
During report, the nurse is given all of the following information. Which client should the nurse go to first?
- A. A diabetic has a blood sugar of 200.
- B. A client who had abdominal surgery earlier today is complaining of operative site pain.
- C. A client who had abdominal surgery yesterday has crackles on auscultation.
- D. A client who had a thyroidectomy earlier today is complaining of muscle spasms.
Correct Answer: D
Rationale: Muscle spasms post-thyroidectomy suggest hypocalcemia from parathyroid injury, a potentially life-threatening emergency requiring immediate assessment. High glucose, pain, or crackles are less urgent.