Nokea
The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching?
- A. I should avoid getting water in the eye for 3 to 7 days after surgery.'
- B. It is okay for me to resume normal chores such as vacuuming.'
- C. It is okay for me to have green or yellow, thick drainage from the eye.'
- D. I may take aspirin for any pain I may experience.'
Correct Answer: A
Rationale: Avoiding water in the eye for 3-7 days post-cataract surgery prevents infection. Heavy chores like vacuuming, abnormal drainage, and aspirin use (which risks bleeding) are contraindicated.
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The client with a laryngectomy communicates to the nurse that he does not want his family to see him. He indicates that he thinks the opening in his throat is disgusting. Which of the following nursing diagnoses would be most appropriate?
- A. Deficient knowledge about the care of a stoma.
- B. Disturbed personal identity related to change in appearance.
- C. Disturbed body image related to neck surgery.
- D. Hopelessness related to irreversible changes in body functioning.
Correct Answer: C
Rationale: Disturbed body image related to neck surgery addresses the client's negative feelings about the stoma's appearance. Deficient knowledge is less relevant here. Disturbed personal identity is broader. Hopelessness implies a deeper psychological state not fully supported by the description.
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?
- A. A client with an endotracheal tube transferred out of the intensive care unit that day.
- B. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
- C. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
- D. A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.
Correct Answer: A,C,B,D
Rationale: The client with a new endotracheal tube (A) is highest priority due to airway risk. The febrile client with cellulitis (C) is next for infection monitoring. The stroke client (B) is stable 4 days post-event. The I.V. fluid client (D) is lowest priority.
The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age?
- A. Poor posture.
- B. Little mass.
- C. Dull expression.
- D. Weight of 128 lb (58.1 kg).
Correct Answer: B
Rationale: Little mass in a 5'7' female suggests low body weight or muscle wasting, indicative of poor nutrition. A weight of 128 lb is within a healthy range, and poor posture or dull expression are less specific to nutritional status.
A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
- A. Treatment of recurrent malignant effusion.
- B. Diagnosis of underlying disease.
- C. Palliation of symptoms.
- D. Relief of acute respiratory distress.
- E. Removal of the cancer cells.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (B), palliates symptoms like dyspnea (C), and relieves acute respiratory distress (D). It does not treat recurrent effusions or remove cancer cells.
A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which of the following indicates that the nurse needs to contact the surgeon for further communication with the client?
- A. We talked about the effect of my diabetes on healing.'
- B. œThe surgeon explained how the craniotomy was done.'
- C. œThere are no major risks from this surgery.'
- D. œI will die if the tumor is not removed from my brain.'
Correct Answer: C
Rationale: Stating there are no major risks indicates a misunderstanding, as craniotomy carries significant risks (e.g., bleeding, infection). The nurse must contact the surgeon to clarify risks for informed consent.