Nokea
The nurse is caring for a client following a cataract removal from their left eye. Which statement by the client's wife indicates an understanding of the post-operative care instructions?
- A. He should sleep on his left side.'
- B. He should sleep on his right side.'
- C. I will need to give him postoperative antibiotic eye drops every hour.'
- D. He needs to sleep sitting completely upright.'
Correct Answer: B
Rationale: Sleeping on the unaffected (right) side prevents pressure on the operated left eye. Sleeping on the left side risks complications, hourly eye drops are excessive, and sleeping upright is not typically required.
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Bethanechol (Urecholine) has been ordered for a client with gastroesophageal reflux disease (GERD). The nurse should assess the client for which of the following adverse effects?
- A. Constipation.
- B. Urinary urgency.
- C. Hypertension.
- D. Dry oral mucosa.
Correct Answer: B
Rationale: Bethanechol, a cholinergic agent, can cause urinary urgency as an adverse effect due to its stimulation of smooth muscle contraction, including in the bladder.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
- A. Stopping smoking
- B. Wearing a face covering and gloves in the winter
- C. Placing fingertips in cool water to rewarm them
- D. Finding employment that can be done in a warm environment
- E. Reporting signs of orthostatic hypotension
Correct Answer: A,B,D,E
Rationale: Rationales: A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's. B) Face covering and gloves protect against cold, a trigger for vasospasm. D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring. C) Cool water worsens vasospasm; warm water is recommended.
A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
- A. Serum potassium is 3.5 mEq/L.
- B. Blood pressure is 88/46.
- C. ST elevation is present on the electrocardiogram.
- D. Heart rate is 61.
Correct Answer: B
Rationale: Nitroglycerin causes vasodilation, which can lower blood pressure. A blood pressure of 88/46 indicates hypotension, a significant concern as it may compromise perfusion, making it the priority assessment.