Nokea
The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjogren's syndrome. Which client statement indicates the need for further teaching?
- A. After applying the ointment, I'll close my eyes tightly and rub the lid for 2-3 minutes.
- B. I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge.
- C. I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment.
- D. I'll use my ointment at bedtime and my eyedrops during the day.
Correct Answer: A
Rationale: Rubbing the eyes after applying ointment (A) can cause irritation or displace the medication, indicating a need for further teaching. The other statements (B, C, D) reflect correct administration techniques.
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The nurse is screening clients for those at risk of developing nephrolithiasis. Which of the following factors would increase a client's risk of developing nephrolithiasis?
- A. gout
- B. dehydration
- C. hypokalemia
- D. thrombocytopenia
- E. hyperparathyroidism
Correct Answer: A,B,E
Rationale: Gout (A), dehydration (B), and hyperparathyroidism (E) increase nephrolithiasis risk due to uric acid, concentrated urine, and calcium imbalances, respectively. Hypokalemia (C) and thrombocytopenia (D) are unrelated.
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
- A. Teaching the child self care skills
- B. Preparing for independent toileting
- C. Promoting the child's optimal development
- D. Helping the family decide on long term care
Correct Answer: C
Rationale: Promoting the child's optimal development. The primary goal is to promote the child's optimum development.
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is
- A. Drop the canister in water to observe floating
- B. Estimate how many doses are usually in the canister
- C. Count the number of doses as the inhaler is used
- D. Shake the canister to detect any fluid movement
Correct Answer: A
Rationale: Dropping the canister into a bowl of water assesses the amount of medication remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. liver cirrhosis who has a decreased RBC count and is reporting pruritis
- B. pneumonia who has an elevated WBC count and coarse crackles bilaterally
- C. atrial fibrillation who has an irregular heart rate of 122/min and is reporting palpitations
- D. pericarditis who has muffled heart sounds and a decrease in systolic blood pressure of 20 mm Hg with inspiration
Correct Answer: D
Rationale: Pericarditis with paradoxical pulse (D) suggests tamponade, requiring immediate assessment. Atrial fibrillation (C), pneumonia (B), and cirrhosis (A) are less urgent.
The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.