Nokea
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
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All of the following clients assigned to LPN/LVN ring their call bells. Which client needs the most immediate attention?
- A. A 72-year-old diabetic who is blind says she has to go to the bathroom.
- B. A 75-year-old client who has rheumatoid arthritis asks for pain medication.
- C. A client who has a blood transfusion running says her chest hurts.
- D. A postoperative client says he is in pain and wants a pain shot.
Correct Answer: C
Rationale: Chest pain during a blood transfusion suggests a possible transfusion reaction, a life-threatening emergency requiring immediate intervention. Bathroom needs, arthritis pain, or postoperative pain are less urgent.
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
The nurse is administering prescribed medications to assigned clients. The nurse should hold and seek clarification for which scheduled administrations? Select all that apply.
- A. client with cirrhosis had 2 stools today, lactulose prescribed daily
- B. client receiving IV vancomycin; mild facial flushing noted after 30 minutes
- C. client scheduled for abdominal surgery tomorrow; vitamin E PO prescribed daily
- D. client prescribed lisinopril PO daily; serum potassium level is 5.6 mEq/L (5.6 mmol/L)
- E. client with diabetes mellitus has insulin glargine and aspart prescribed, AM glucose is 100 mg/dL (5.6 mmol/L)
Correct Answer: B, C, D
Rationale: Vancomycin flushing (B) suggests red man syndrome, vitamin E (C) increases bleeding risk pre-surgery, and hyperkalemia (D) contraindicates lisinopril. Lactulose (A) and insulin (E) are appropriate.
The nurse is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse administer to the client? Select all that apply.
- A. albuterol
- B. buproten
- C. ipratropium
- D. tobramycin
- E. montelukast
Correct Answer: A, C
Rationale: Albuterol (A) and ipratropium (C) are bronchodilators used in acute asthma exacerbations. Ibuprofen (B), tobramycin (D), and montelukast (E) are not indicated for acute management.
An adult client in an acute care facility says to the nurse, 'I hope this hospital doesn't have student doctors and nurses. I do not want a student taking care of me.' The nurse's response should be based on which of the following understandings?
- A. When a client signs permission for treatment in a hospital, this includes treatment by medical and nursing students.
- B. The client has the right to know if the hospital is affiliated with a medical school and to refuse care by students.
- C. The client may sign a special form that says he refuses to be cared for by medical or nursing students.
- D. The client should be informed if any caregivers are students, but the client does not have the right to refuse to be cared for by students.
Correct Answer: B
Rationale: Clients have the right to know about student involvement and refuse student care, respecting autonomy. Consent doesn't inherently include students, and special forms or mandatory acceptance are incorrect.
A postoperative client with obesity and diabetes mellitus has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply.
- A. Administer docusate sodium orally every day
- B. Assist in applying an abdominal binder
- C. Implement caloric restriction to promote weight loss
- D. Monitor blood glucose to maintain tight control
- E. Reinforce teaching to hug a pillow while coughing
Correct Answer: B, D, E
Rationale: Abdominal binder (B), glucose control (D), and pillow hugging (E) reduce wound stress and promote healing. Docusate (A) prevents constipation but not dehiscence, and caloric restriction (C) is inappropriate post-surgery.