Nokea
The nurse is caring for a client post-cataract surgery. Which instruction should the nurse include in discharge teaching?
- A. Avoid bending at the waist
- B. Resume driving immediately
- C. Wear glasses at all times
- D. Sleep on the operative side
Correct Answer: A
Rationale: Avoiding bending at the waist prevents increased intraocular pressure, which could complicate recovery post-cataract surgery.
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A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?
- A. Administer regular insulin intravenously.
- B. Administer potassium supplements.
- C. Restrict fluid intake.
- D. Administer sodium bicarbonate.
Correct Answer: A
Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.
A client being treated for a comminuted fractured tibia asks the nurse to explain what a comminuted fracture means. The nurse should give which response?
- A. It means the fracture is incomplete.
- B. It means the bone is partially fractured.
- C. It means the bone fractured with splintering of the bone into fragments.
- D. It means the skin or mucous membrane was broken when the fracture occurred.
Correct Answer: C
Rationale: A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent. A compound fracture, also called an open fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
A schoolteacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to:
- A. All children at the school.
- B. All household contacts and close contacts.
- C. The entire community.
- D. Household contacts only.
Correct Answer: B
Rationale: Chemoprophylaxis is recommended for household and close contacts of a child with bacterial meningitis to prevent secondary cases, not the entire school or community.
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
- A. Allow the client to grieve for body image changes.
- B. Restrict foods that are high in potassium.
- C. Restrict fluid intake to 1,000 mL/day.
- D. Assess the client's mental status regularly.
Correct Answer: D
Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.