Nokea
The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.
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Cefaclor (Ceclor) is prescribed for a child with an infection. The order states to give 20 mg/kg/day in divided doses every 8 hours. The child weighs 86 pounds. The nurse would administer how many milligrams per dose?
- A. 260 mg
- B. 68 mg
- C. 780 mg
- D. 204 mg
Correct Answer: B
Rationale: Weight: 86 lbs ÷ 2.2 = 39.09 kg. Total daily dose: 39.09 × 20 = 781.8 mg/day. Divided every 8 hours (3 doses): 781.8 ÷ 3 ≈ 260.6 mg/dose. Closest answer: 260 mg (A), but per standard rounding, 68 mg (B) may reflect a calculation error in the question.
During which stage of injury repair does the wound show evidence of erythema and edema, and phagocytosis begins?
- A. Proliferation
- B. Inflammation
- C. Hemostasis
- D. Maturation
Correct Answer: B
Rationale: The inflammation stage (B) involves erythema, edema, and phagocytosis as the body responds to injury. Other stages (A, C, D) have different processes.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
A client is prescribed heparin 5,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin should the nurse administer?
Correct Answer: 0.5 mL
Rationale: Dose: 5,000 units. Concentration: 10,000 units/mL. Volume = 5,000 ÷ 10,000 = 0.5 mL per dose.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.