Nokea
The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client?
- A. Have the client demonstrate placing the otic drops in the ear.
- B. Teach the client to instill the eyedrops as prescribed.
- C. Remind the client to keep the lights in the home low at all times.
- D. Encourage the client to sleep on two pillows at night.
Correct Answer: B
Rationale: Instilling prescribed eyedrops (e.g., antibiotics, steroids) prevents infection and inflammation post-cataract surgery. Otic drops are irrelevant, low lights are unnecessary, and elevation is not standard.
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The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).
The client with severe otitis media and mastoiditis is prescribed levofloxacin IV, 250 mg every 12 hours. The medication is diluted in 100 mL of NS. To deliver the antibiotic in 30 minutes, the nurse must infuse the solution at a rate of how many mL per hour?
- A. 200
Correct Answer: A
Rationale: The rate of IV infusion is calculated as follows: 100 mL over 30 minutes equals X mL over 60 minutes. Thus, 100/30 = X/60, so X = (100 × 60) / 30 = 200 mL/hr.
The client recently diagnosed with age-related macular degeneration (AMD) in both eyes returns to the clinic for a follow-up appointment. Which assessment will the nurse be certain to include during the visit?
- A. Stools for occult blood
- B. Blood glucose levels
- C. Screening for depression
- D. Screening for hearing loss
Correct Answer: C
Rationale: The nurse should assess for depression because loss of vision can affect functional ability, mood, and quality of life. Depression frequently develops within a few months after AMD is diagnosed in both eyes. GI bleeding, blood glucose, and hearing loss are not directly related to AMD.
The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make?
- A. Install fluorescent lighting throughout the home.
- B. Wear sunglasses and hats with brims when outdoors.
- C. Avoid going outdoors on days that are sunny.
- D. Use direct sunlight from windows rather than lights.
Correct Answer: B
Rationale: Wearing sunglasses and hats with brims while outdoors blocks direct light, reducing glare. Fluorescent lighting and direct sunlight increase glare, and avoiding sunny days is unnecessary.
The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.