Nokea
The nurse is caring for a client with a history of a retinal detachment who is scheduled for a scleral buckling procedure. The nurse should:
- A. Position the client flat in bed
- B. Administer eye drops as ordered
- C. Restrict fluids before surgery
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Eye drops (e.g., mydriatics) are often ordered pre-scleral buckling to dilate the pupil or reduce pressure. Flat positioning, fluid restriction, and breathing exercises are not standard.
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The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.
The nurse is caring for a client with a history of type 2 diabetes. The nurse should expect the client to have:
- A. Polyuria
- B. Weight loss
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: Type 2 diabetes causes hyperglycemia, leading to polyuria due to osmotic diuresis.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
A 72-year-old client with a new colostomy is being evaluated at the clinic today for constipation. When discussing diet with the client, the nurse recognizes that which one of the following foods most likely caused this problem?
- A. Fried chicken
- B. Eggs
- C. Tapioca
- D. Cabbage
Correct Answer: C
Rationale: Fried, greasy food, such as fried chicken, will produce diarrhealike stools in individuals with all types of GI ostomies. Eggs will cause odor-producing stools in individuals with all types of GI ostomies. Tapioca and rice products will cause constipation in individuals with all types of GI ostomies. Cabbage will cause odor-producing and flatus-producing stools in individuals with all types of GI ostomies.
Which nursing implication is appropriate for a client undergoing a paracentesis?
- A. Have the client void before the procedure.
- B. Keep the client NPO.
- C. Observe the client for hypertension following the procedure.
- D. Place the client on the right side following the procedure.
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.