Nokea
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.
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A client who underwent a left lower lobectomy has been out of surgery for 48 hours. She is receiving morphine sulfate via a patient-controlled analgesia (PCA) system. She tells the nurse that she has some pain in her left thorax that worsens when she coughs. The nurse should:
- A. I don't be silent, so that she is not stimulated to cough.
- B. Encourage the client to take deep breaths to help control the pain.
- C. Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve her pain.
- D. Obtain a more detailed assessment of the client's pain using a pain scale.
Correct Answer: D
Rationale: A detailed pain assessment using a scale clarifies the pain's severity and guides adjustments to analgesia. Silencing the client or encouraging deep breaths may worsen pain. Checking the PCA is appropriate but secondary to assessment.
A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, 'How can that be? I'm not imagining all these symptoms!' The nurse's response will be based on which of the following?
- A. Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels.'
- B. A single random blood test cannot provide reliable information about endocrine levels.'
- C. The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern.'
- D. Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.'
Correct Answer: C
Rationale: Cushing's disease disrupts the normal diurnal cortisol rhythm, leading to consistently high levels, which may not be captured in a single morning test.
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients?
- A. A client awaiting surgery for a hiatal hernia repair at 11 a.m.
- B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests.
- C. A client with peptic ulcer disease experiencing a sudden onset of acute stomach pain.
- D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw.
Correct Answer: C
Rationale: The client with sudden onset of acute stomach pain (C) should be assessed first, as this could indicate a serious complication like ulcer perforation. The other clients' conditions are less urgent: the hiatal hernia client is stable, the NPO client is awaiting tests, and the jaw surgery client's pain is expected postoperatively.
A client with acute renal failure reports shortness of breath. The nurse should:
- A. Administer oxygen.
- B. Increase fluid intake.
- C. Check lung sounds.
- D. Encourage coughing.
Correct Answer: C
Rationale: Shortness of breath may indicate fluid overload; lung sounds assess for pulmonary edema.