Nokea
The nurse is providing instructions to the mother of a child with a diagnosis of strabismus of the left eye. Which statement by the mother indicates that the mother understands the procedure for patching?
- A. I will place the patch on both eyes.
- B. I will place the patch on the left eye.
- C. I will place the patch on the right eye.
- D. I will alternate the patch from the right eye to the left eye every hour.
Correct Answer: C
Rationale: Patching may be used for the treatment of strabismus to strengthen the weak eye. With this treatment, the good eye is patched; this encourages the child to use the weaker eye. The treatment is most successful when it is performed during the preschool years. The schedule for patching is individualized and prescribed by the ophthalmologist.
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A goal for a postpartum client states, 'The client will remain free of infection during her hospital stay.' Which assessment data would support that the goal has been met?
- A. Normal appetite
- B. Absence of fever
- C. Minimal vaginal bleeding
- D. Moderate breast tenderness
Correct Answer: B
Rationale: Fever is the first indication of an infection. Therefore, the absence of a fever indicates that an infection is not present. The remaining options are not associated with a postpartum infection.
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication?
- A. Hypokalemia
- B. Hypernatremia
- C. Hypochloremia
- D. Hypercalcemia
Correct Answer: A
Rationale: Clients receiving amphotericin B may develop hypokalemia, which can be severe and lead to extreme muscle weakness and electrocardiogram changes. Distal renal tubular acidosis commonly occurs, and this contributes to the development of hypokalemia. High potassium levels do not occur. The medication does not cause sodium, chloride, or calcium levels to fluctuate.
A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?
- A. Nausea
- B. Heartburn
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Trimethobenzamide is an antiemetic agent that is used for the treatment of nausea and vomiting. The medication is not used to treat heartburn, constipation, or abdominal pain.
An adult client with hyperkalemia is prescribed sodium polystyrene sulfonate. Which serum potassium level is a clinical indicator of effective therapy?
- A. 4.9 mEq/L (4.9 mmol/L)
- B. 5.4 mEq/L (5.4 mmol/L)
- C. 5.8 mEq/L (5.8 mmol/L)
- D. 6.2 mEq/L (6.2 mmol/L)
Correct Answer: A
Rationale: The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Option 1 is the only option that reflects a value within this range. The remaining options identify hyperkalemic levels.
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
- A. I am in control of myself now.
- B. I need to use the restroom right away.
- C. I'd like to go back to my room and be alone for a while.
- D. I can't breathe in here. It feels like the walls are closing in on me.
Correct Answer: A
Rationale: Option 1 indicates that the client may be safely removed from seclusion. The client in seclusion must be assessed at regular intervals (usually every 15 to 30 minutes) for physical needs, safety, and comfort. Option 2 indicates a physical need that could be met with a urinal, bedpan, or commode; it does not indicate that the client has calmed down enough to leave the seclusion room. Option 3 could be an attempt to manipulate the nurse; it gives no indication that the client will control himself or herself when alone in the room. Option 4 could be handled by supportive communication or an as-needed medication, if indicated; it does not necessitate discontinuing seclusion.