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The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?
- A. Avoid straining, bending, or lifting heavy objects.
- B. Limit exposure to sunlight for the first 2 weeks.
- C. Irrigate the conjunctiva with saline before applying ointment.
- D. Read without direct lighting for 6 weeks.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.
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An 11-year-old client admitted to the mental health unit after threatening self-harm. What is the best activity to establish rapport and promote coping?
- A. Bring the client to the team meeting to discuss the treatment plan.
- B. Play a board game with the client and start discussing stressors.
- C. Explain the purpose of each medication the client is taking.
- D. Ask the client to write feelings in a journal and review together.
Correct Answer: B
Rationale: Playing a board game with the client is an effective way to establish rapport in a relaxed setting, allowing the client to open up about stressors. This activity promotes coping by creating a safe and engaging environment for the client to express their feelings. Choices A, C, and D may not be suitable initially as they involve more formal or intrusive approaches that may not be suitable for building rapport with a client experiencing emotional distress.
A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?
- A. Increase the dosage of the medication.
- B. Auscultate bowel sounds.
- C. Monitor the client's blood pressure.
- D. Check the client's respiratory rate.
Correct Answer: B
Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.
A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?
- A. Instruct the client to immediately see her provider for an evaluation
- B. Assess the fluid for signs of infection
- C. Explain that this normal secretion can be assessed at the next visit
- D. Recommend breast ultrasound to rule out abnormalities
Correct Answer: C
Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (Choice A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (Choice B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (Choice D) is premature without further assessment by the healthcare provider.
A client with hypocalcemia is receiving calcium gluconate. What assessment finding requires immediate intervention?
- A. Decreased deep tendon reflexes.
- B. Wheezing and stridor.
- C. Decreased bowel sounds.
- D. Positive Chvostek's sign.
Correct Answer: B
Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.
A client with chronic obstructive pulmonary disease (COPD) is being discharged home. What should the nurse include in the discharge teaching?
- A. Limit fluid intake to prevent lung congestion
- B. Avoid all physical activity to conserve energy
- C. Perform pursed-lip breathing during activities
- D. Increase oxygen flow rate if shortness of breath occurs
Correct Answer: C
Rationale: The correct answer is C. Pursed-lip breathing helps control breathing and improves oxygen exchange in clients with COPD. It can ease shortness of breath during activities and should be included in discharge teaching to manage symptoms. Option A is incorrect as adequate fluid intake is important for thinning mucus in COPD. Option B is wrong as physical activity, as tolerated, is beneficial for COPD patients. Option D is also incorrect because changing oxygen flow rate without healthcare provider guidance can be dangerous.