Nokea
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
- A. Avoid activities that elicit Valsalva's maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.
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A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
- A. Avoid heating pads
- B. Not cross her legs
- C. Wear leather shoes
- D. Use iodine on an injured site
Correct Answer: D
Rationale: Using iodine on an injured site is incorrect, as it can be cytotoxic and impair wound healing in PVD, where tissue perfusion is already compromised. Avoiding heating pads (risk of burns), not crossing legs (improves circulation), and wearing leather shoes (protects feet) are appropriate self-care measures.
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.
- A. Blue eyes
- B. Older age
- C. African ethnicity
- D. Diabetes mellitus
- E. Use of contact lenses
Correct Answer: B,C,D
Rationale: Older age, African ethnicity, and diabetes mellitus are known risk factors for primary open-angle glaucoma due to increased intraocular pressure susceptibility. Blue eyes and contact lens use are not established risk factors.
A client is admitted with a bowel obstruction. The client has nausea, vomiting, and crampy abdominal pain. The physician has written orders for the client to be up ad lib, to have narcotics for pain, to have a nasogastric tube inserted if needed, and for I.V. Ringer's Lactate and hyperalimentation fluids. The nurse should do the following in order of priority from first to last:
- A. Assist with ambulation to promote peristalsis.
- B. Administer Ringer's Lactate.
- C. Insert a nasogastric tube.
- D. Start an infusion of hyperalimentation fluids.
Correct Answer: B,C,A,D
Rationale: The priority is to administer Ringer's Lactate (B) to correct dehydration, followed by inserting a nasogastric tube (C) if needed to decompress the bowel. Ambulation (A) can promote peristalsis but is less urgent, and hyperalimentation fluids (D) are started later for long-term nutrition. CN: Physiological adaptation; CL: Synthesize
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.
When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply.
- A. Becoming increasingly short of breath at rest.
- B. Weight gain of 2 lb or more in 1 day.
- C. High intake of sodium for breakfast.
- D. Having to sleep sitting up in a reclining chair.
- E. Weight loss of 2 lb in 1 day.
Correct Answer: A,B,D
Rationale: Shortness of breath at rest (A), weight gain of 2 lb or more in 1 day (B), and sleeping sitting up (D) indicate worsening heart failure, requiring physician notification.