Nokea
The client with glaucoma is scheduled for a hip replacement. Which of the following orders would require clarification before the nurse carries it out?
- A. Administer morphine sulfate.
- B. Administer atropine sulfate.
- C. Teach deep-breathing exercises.
- D. Teach leg lifts and muscle-setting exercises.
Correct Answer: B
Rationale: Atropine sulfate can increase intraocular pressure, which is contraindicated in glaucoma. The nurse should clarify this order to ensure it is safe for the client.
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Which statement by a client with acute renal failure indicates understanding of dietary restrictions?
- A. I will avoid oranges.
- B. I can eat unlimited protein.
- C. I should drink less water.
- D. I will eat more spinach.
Correct Answer: A
Rationale: Oranges are high in potassium, which should be avoided in acute renal failure.
The nurse is preparing to administer a unit of packed red blood cells (PRBCs). The nurse should
- A. obtain a bag of 250 mL of 0.9% saline.
- B. obtain a bag of 250 mL of Dextrose 5% in water (D5W).
- C. insert a 22 gauge intravenous (IV) catheter.
- D. initiate continuous telemetry monitoring.
Correct Answer: A
Rationale: 0.9% saline is required to prime the tubing for PRBC transfusions, as it is compatible and prevents hemolysis. D5W causes hemolysis, a 22-gauge catheter is too small for blood products, and telemetry is not routinely required.
The nurse observes the client instill eyedrops. The client says, 'I just try to hit the middle of my eyeball so the drops don't run out of my eye.' The nurse explains to the client that this method may cause:
- A. Corneal abrasion.
- B. Increased intraocular pressure.
- C. Systemic absorption of the medication.
- D. Ineffective distribution of the medication.
Correct Answer: A
Rationale: Instilling eyedrops directly onto the cornea (middle of the eyeball) can cause corneal abrasion due to the dropper tip or improper technique. Drops should be placed in the lower conjunctival sac.
The nurse monitors the client with pancreatitis for early signs of shock. Which of the following conditions is primarily responsible for making it difficult to manage shock in pancreatitis?
- A. Severity of intestinal hemorrhage.
- B. Loss of fluids into the retroperitoneal space.
- C. Infection from pancreatic necrosis.
- D. Decreased cardiac output.
Correct Answer: B
Rationale: In pancreatitis, fluid sequestration into the retroperitoneal space (B) causes hypovolemia, complicating shock management. Intestinal hemorrhage (A), infection (C), and decreased cardiac output (D) are less primary contributors.
The nurse is conducting discharge education with a client newly diagnosed with Addison's disease. Which information should be included in the client and family teaching plan? Select all that apply.
- A. Addison's disease will resolve over a few weeks, requiring no further treatment.
- B. Avoiding stress and maintaining a balanced lifestyle will minimize risk for exacerbations.
- C. Fatigue, weakness, dizziness, and mood changes need to be reported to the physician.
- D. A medical identification bracelet should be worn.
- E. Family members need to be informed about the warning signals of adrenal crisis.
- F. Dental work or surgery will require adjustment of daily medication.
Correct Answer: B,C,D,E,F
Rationale: Addison's is chronic, requiring lifelong management. Stress management, symptom reporting, medical ID, family education, and medication adjustments for procedures are critical.