Nokea
The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply.
- A. Teach the client how to instill eye drops.
- B. Instruct the client not to lie on the affected side.
- C. Remind the client that a reduction of vision is normal.
- D. Provide the client with an eye patch for the affected eye.
- E. Educate the client to avoid bending at the waist.
Correct Answer: A,B,D,E
Rationale: Post-phacoemulsification care includes teaching eye drop instillation, avoiding lying on the affected side, using an eye patch for protection, and avoiding bending to prevent pressure increase. Reduced vision is not normal and requires evaluation.
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The nurse is preparing to administer prescribed medications to a client via a nasogastric tube connected to low-intermittent suction. The nurse should take which appropriate action? Select all that apply.
- A. Position the client in Trendelenburg position.
- B. Verify correct placement of the tube before medication administration.
- C. Turn off the suction during medication administration.
- D. Resume low-intermittent wall suction immediately after medication administration.
- E. Irrigate the nasogastric tube (NGT) with sterile water.
Correct Answer: B,C
Rationale: Verifying tube placement and turning off suction ensure safe medication administration; Trendelenburg is inappropriate, and sterile water is not required.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The nurse is caring for a client reporting an abrupt onset of severe pain associated with metastatic cancer. Which prescription should the nurse plan to administer?
- A. fentanyl via transdermal patch
- B. pregabalin
- C. ketorolac
- D. hydromorphone
Correct Answer: D
Rationale: Hydromorphone is appropriate for rapid relief of severe, acute cancer pain due to its fast-acting opioid properties.
A 68-year-old client with colon cancer experiences an increase in his feelings of anxiety and depression and has suicidal ideation. He appears to be in great distress. The nurse realizes that he is at which stage in his disease?
- A. Initiation of definitive treatment.
- B. End of his first course of treatment.
- C. End stage of his disease.
- D. Recurrence of the disease.
Correct Answer: C
Rationale: Increased anxiety, depression, and suicidal ideation suggest the client is in the end stage of colon cancer, facing mortality and existential distress.