Nokea
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following statements by the client indicates a need for further teaching?
- A. I should use this medication at bedtime.
- B. I should report eye pain to my doctor.
- C. I should avoid rubbing my eyes after using it.
- D. I should stop this medication if my vision improves.
Correct Answer: D
Rationale: Stopping latanoprost when vision improves is incorrect, as glaucoma requires lifelong treatment to prevent optic nerve damage. Options A, B, and C are correct: bedtime dosing is standard, eye pain may indicate complications, and avoiding rubbing prevents irritation.
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The nurse is caring for a client who is postoperative day 1 after a cholecystectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site
- B. Temperature of 100.8°F (38.2°C)
- C. Bile-colored drainage from the T-tube
- D. Urine output of 40 mL/hour
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-cholecystectomy complication. Options A, C, and D are normal: pain is expected, bile drainage is typical, and urine output is adequate.
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux