Nokea
The nurse is instructing the client about postsurgery activity following cataract surgery. What position should the nurse teach the client to use?
- A. Remain in a semi-Fowler's position.
- B. Position the feet higher than the body.
- C. Lie on the operative side.
- D. Place the head in a dependent position.
Correct Answer: A
Rationale: A semi-Fowler's position (head elevated 30-45 degrees) helps reduce intraocular pressure and swelling by promoting drainage and preventing fluid accumulation in the surgical eye.
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The nurse teaches a client with chronic obstructive pulmonary disease for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan?
- A. Clubbing of nail beds.
- B. Hypertension.
- C. Peripheral edema.
- D. Increased appetite.
Correct Answer: C
Rationale: Right-sided heart failure (cor pulmonale) in COPD causes peripheral edema due to increased venous pressure. Clubbing reflects chronic hypoxia, not heart failure. Hypertension and increased appetite are unrelated.
Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply.
- A. Call in extra staff to assist with the possibility of more clients with the same condition.
- B. Isolate all the suspected clients in the emergency department in one area.
- C. Call housekeeping for diluted household bleach.
- D. Restrict visitors from the emergency department.
- E. Quarantine all contacts.
Correct Answer: A,B,C,D,E
Rationale: Ebola requires comprehensive measures: extra staff for surge capacity, isolation to prevent spread, bleach for disinfection, visitor restrictions, and contact quarantine to control the outbreak.
The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.
A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
The nurse is teaching a client with a new colostomy about dietary modifications. Which of the following foods should the client avoid to prevent excessive gas?
- A. Broccoli.
- B. Chicken.
- C. Rice.
- D. Yogurt.
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, can cause excessive gas in clients with a colostomy, which may lead to pouch ballooning. Chicken, rice, and yogurt are less likely to produce significant gas. CN: Physiological adaptation; CL: Synthesize