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The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Infection.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.
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A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
- A. Take the medication with sips of water.
- B. Lie on the right side after taking the medication.
- C. Hyperextend the neck for 30 seconds before swallowing.
- D. Void within at least 10 minutes before taking the medication.
Correct Answer: A
Rationale: Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to swallow. In this situation, there is no reason for the client to lie down to swallow medication or hyperextend the neck. Additionally, lying down could place the client at risk for aspiration. There is no specific reason for the client to void before taking the medication.
When developing the plan of care for a 14-year-old boy with a nursing diagnosis of Deficient diversional activity related to immobility, which of the following activities is most appropriate?
- A. Playing a card game with a boy the same age.
- B. Putting together a puzzle with his mother.
- C. Playing video games with a 9-year-old.
- D. Watching a movie with his younger brother.
Correct Answer: A
Rationale: A peer-based activity like a card game promotes social interaction and engagement, suitable for a 14-year-old's developmental needs.
A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
- A. Instill the eyedrops whenever the eyes feel irritated
- B. The medication may cause some transient eye discomfort
- C. Keep the medication refrigerated between doses
- D. The need to use the eyedrops will be reevaluated after 1 month
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.
The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?
- A. Vital signs
- B. Motor function
- C. Sensory function
- D. Level of consciousness
Correct Answer: D
Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.
The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?
- A. Bladder spasms
- B. Bleeding within the bladder
- C. Tension on the Foley catheter
- D. The lower abdominal incision
Correct Answer: A
Rationale: Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Options 2 and 3 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. There is no incision with a TURP.