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The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. The nurse should:
- A. Allow the client to keep the eye drops at the bedside and use as prescribed on the bottle.
- B. Place the eye drops in the medication drawer and administer as labeled on the bottle.
- C. Explain to the client that the physician will write an order for the eye drops to be used at the hospital.
- D. Ask the client's wife to assist the client in administering the eye drops while the client is in the hospital.
Correct Answer: C
Rationale: The nurse should explain that the physician needs to write an order for the eye drops to ensure they are appropriate and safe for hospital use, maintaining medication safety protocols.
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A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has measured the correct dose when the syringe reads how many units?
Correct Answer: 32 units.
Rationale: The total dose is 10 units regular + 22 units NPH = 32 units, which should be drawn into one syringe for administration.
The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
- A. Adjust the infusion rate to match the order.
- B. Contact the prescribing physician for clarification.
- C. Continue the current infusion rate.
- D. Document the discrepancy in the client's chart.
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.