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The nurse is reviewing the postoperative orders (see chart) just written by a physician for a client with insulin-dependent diabetes who has returned to the surgery floor from the recovery. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should do which of the following first?
- A. Administer the morphine.
- B. Contact the physician to report the glucose level and rewrite the insulin order.
- C. Administer oxygen per nasal cannula at 2 L/minute.
- D. Take the vital signs.
Correct Answer: B
Rationale: The glucose level must be assessed to determine if insulin is safe to administer, as hypoglycemia could worsen with insulin. Contacting the physician ensures appropriate insulin dosing.
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Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
- A. Anemia.
- B. Osteoporosis.
- C. Weight loss.
- D. Local joint pain.
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.
The nurse observes the client instill eyedrops. The client says, 'I just try to hit the middle of my eyeball so the drops don't run out of my eye.' The nurse explains to the client that this method may cause:
- A. Corneal abrasion.
- B. Increased intraocular pressure.
- C. Systemic absorption of the medication.
- D. Ineffective distribution of the medication.
Correct Answer: A
Rationale: Instilling eyedrops directly onto the cornea (middle of the eyeball) can cause corneal abrasion due to the dropper tip or improper technique. Drops should be placed in the lower conjunctival sac.
Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:
- A. Altered balance.
- B. Altered protective pressure sensation.
- C. Impaired hearing ability.
- D. Impaired visual acuity.
Correct Answer: B
Rationale: Older adults have reduced pressure sensation due to thinner skin and nerve changes, increasing the risk of skin breakdown and pressure ulcers.
During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem?
- A. Visit her friend early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down once she reaches the friend's apartment.
Correct Answer: C
Rationale: Taking sublingual nitroglycerin before exertion (e.g., climbing stairs) prevents angina by dilating coronary arteries, increasing myocardial oxygen supply.
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.