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The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
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A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.
The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.
- A. I gave acetaminophen 500 mg PO to the client for a headache, with good relief.
- B. The client had morphine 15 mg PO 45 minutes ago for leg pain and now reports 3 on a pain scale of 0-10.
- C. The client's sisters visited today and were very rude, but they did bring the client's medication list.
- D. The continuous bladder irrigation normal saline infusion bag will need to be replaced at 9 PM.
- E. The radiology department called to say that an ultrasound will be performed at 9 PM.
Correct Answer: A,B,D,E
Rationale: Acetaminophen administration (A), morphine effect (B), irrigation replacement (D), and ultrasound schedule (E) are relevant to care. Family behavior (C) is subjective and inappropriate.
An adult had a thyroidectomy under local anesthesia and is now in the postanesthesia care unit. Which finding is of most concern to the nurse?
- A. The client complains of a sore throat.
- B. The client's hand involuntarily clenches when the nurse checks the blood pressure.
- C. The client is sitting upright in the bed.
- D. The client asks for a drink of water.
Correct Answer: B
Rationale: Involuntary hand clenching (Trousseau's sign) suggests hypocalcemia from parathyroid damage during thyroidectomy, a serious complication requiring immediate attention. Sore throat, upright position, or thirst are less urgent.
Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
- A. Dehydration
- B. Atelectasis
- C. Wound infection
- D. Bladder infection
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.