Nokea
The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
- A. The client demonstrates putting eye drops in the conjunctival sac.
- B. The client has a patch on the affected eye.
- C. The client bends over to pick up the cat.
- D. The client is wearing slip-on shoes.
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
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During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse?
- A. Client cares for a pet dog and a few outdoor cats
- B. Client has gained 4 lb (1.8 kg) during the pregnancy so far
- C. Client reports a nonodorous, milky white vaginal discharge
- D. Client swims in a pool for exercise three times per week
Correct Answer: A
Rationale: Pet cats (A) pose a toxoplasmosis risk, which can cause fetal harm, requiring immediate education and possible testing. Weight gain (B) is normal, milky discharge (C) is typical in pregnancy, and swimming (D) is safe.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal just before retiring
- C. Take sodium bicarbonate and water after each meal
- D. Sleep with head propped on several pillows
Correct Answer: D
Rationale: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
- A. Reduced oxygen capacity of cells due to lack of iron
- B. An imbalance between red cell destruction and production
- C. Depression of red and white cells and platelets
- D. Inability of sickle shaped cells to regenerate
Correct Answer: B
Rationale: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
The nurse is providing dietary teaching for an elderly client living on fixed income. Which food choices would provide the client with needed nutrients and be cost effective?
- A. Potatoes, green beans, bacon
- B. Spinach, dried beans, tomatoes
- C. Ham, corn, strawberries
- D. Beef, cheese, milk
Correct Answer: B
Rationale: Spinach, dried beans, and tomatoes are nutrient-rich (vitamins, protein, fiber) and cost-effective. Bacon , ham , and beef/cheese/milk are more expensive and less balanced.
The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?
- A. Adhesive bandaging should remain on the lesions to prevent virus shedding
- B. Blood tests will be drawn to ensure that the virus is eradicated
- C. Condoms should be used during intercourse until the lesions are healed
- D. Gloves should be used to apply the medication to the lesions
Correct Answer: D
Rationale: Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorte
the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a
herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the
body even when active lesions are healed; however, it is still contagious, even when dormant. The infection
can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be
used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital
herpes; treatment is aimed at relieving symptoms and preventing the spread of infection