Nokea
The nurse is caring for a client diagnosed with glaucoma. The health care provider has ordered timolol maleate. Which finding in the client's history would prompt the nurse to notify the health care provider?
- A. asthma
- B. migraines
- C. atrial fibrillation
- D. urinary tract infection
Correct Answer: A
Rationale: Timolol, a beta-blocker, can exacerbate asthma by causing bronchoconstriction. Other conditions are not contraindications.
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The nurse is caring for a client who was admitted to the burn unit 4 hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hypernatremia is least expected within 4 hours of a burn injury, as fluid shifts typically cause hyponatremia due to third-spacing. Hypovolemia, laryngeal edema, and hyperkalemia are common early findings.
The nurse is assigned a male client with a long-term in-dwelling catheter for incontinence. The nurse plans on performing which of the following to prevent complications?
- A. perform perineal care using sterile technique
- B. irrigate daily with 60 cc normal saline
- C. restrict fluids to 1,500 cc/day
- D. stabilize the catheter on the abdomen
Correct Answer: D
Rationale: Stabilizing the catheter prevents traction and urethral trauma. Perineal care uses clean technique, routine irrigation is unnecessary, and fluid restriction is inappropriate.
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
- A. Using oil- or cream-based soaps
- B. Flossing between the teeth
- C. The intake of salt
- D. Using an electric razor
Correct Answer: B
Rationale: Flossing can cause gum bleeding, increasing infection and bleeding risks in leukemia clients with low platelet counts.
A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is having the desired effect?
- A. Neutrophil count of 60%
- B. Basophil count of 0.5%
- C. Monocyte count of 2%
- D. Reticulocyte count of 1%
Correct Answer: D
Rationale: Increased reticulocyte count indicates effective B12 therapy for anemia.
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
- A. genital herpes.
- B. chlamydia.
- C. hepatitis B.
- D. gonorrhea.
Correct Answer: A
Rationale: Chlamydia, gonorrhea, and hepatitis B are reportable to the CDC. Genital herpes is not nationally reportable, though local regulations may vary.