Nokea
The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
- A. A 58-year-old Caucasian woman with macular degeneration
- B. A 28-year-old Caucasian man with astigmatism
- C. A 58-year-old African American woman with hyperopia
- D. A 28-year-old African American man with myopia
Correct Answer: A
Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.
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Nursing intervention for pregnant patients with diabetes is based on the knowledge that the need for insulin is
- A. varied depending on the stage of gestation.
- B. increased throughout pregnancy and the postpartum period.
- C. decreased throughout pregnancy and the postpartum period.
- D. should not change because the fetus produces its own insulin.
Correct Answer: A
Rationale: Rationale:
1. Insulin needs change during pregnancy due to hormonal changes.
2. During the first trimester, insulin needs may decrease.
3. During the second and third trimesters, insulin needs increase.
4. Postpartum, insulin needs return to pre-pregnancy levels.
Therefore, choice A is correct as insulin needs vary based on gestational stage. Choices B, C, and D are incorrect because insulin needs do not uniformly increase or decrease throughout pregnancy or due to fetal insulin production.
A nurse is preparing to lavage a patient in theemergency department for an overdose. Which tube should the nurse obtain?
- A. Ewald
- B. Dobhoff
- C. Miller-Abbott
- D. Sengstaken-Blakemore
Correct Answer: A
Rationale: The correct answer is A: Ewald tube. This tube is used for gastric lavage due to its large diameter and open end which allows for effective suction of gastric contents. The Ewald tube is specifically designed for gastric lavage and is ideal for removing toxins from the stomach.
Summary of why the other choices are incorrect:
B: Dobhoff tube is a small-bore feeding tube, not suitable for gastric lavage.
C: Miller-Abbott tube is used for intestinal decompression, not gastric lavage.
D: Sengstaken-Blakemore tube is used for esophageal varices, not gastric lavage.
A nurse is charting on a patient’s record. Whichaction will the nurse take that is accurate legally?
- A. Charts legibly
- B. States the patient is belligerent
- C. Writes entry for another nurse
- D. Uses correction fluid to correct error
Correct Answer: A
Rationale: The correct answer is A: Charts legibly. This is accurate legally because clear and legible documentation is crucial for accurately conveying patient information, ensuring continuity of care, and meeting legal standards. Illegible handwriting can lead to errors in patient care and legal issues.
Choice B is incorrect as labeling a patient as "belligerent" without evidence can be perceived as unprofessional and potentially harmful to the patient. Choice C is incorrect as writing an entry for another nurse can lead to inaccurate documentation and legal consequences. Choice D is incorrect because using correction fluid can raise suspicion of tampering with records and compromise the integrity of the documentation.
A blood-soaked peripad weighs 900 g. The nurse would document a blood loss of _____ mL.
- A. 1800
- B. 450
- C. 900
- D. 90
Correct Answer: C
Rationale: The correct answer is C (900 mL) because the weight of 900 g corresponds to a blood loss of the same amount in milliliters. Blood density is close to that of water, so 1 g ≈ 1 mL. Therefore, a blood-soaked peripad weighing 900 g indicates a blood loss of 900 mL. Choice A (1800 mL) is incorrect as it doubles the weight instead of converting it to milliliters. Choice B (450 mL) is incorrect as it halves the weight. Choice D (90 mL) is incorrect as it divides the weight by 10, which is too small for the blood loss indicated.
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
- A. Application of topical antibiotic ointment
- B. Maintenance of a supine position for the first 48 hours postoperative
- C. Fluid restriction to prevent orbital edema
- D. Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing Chapter 64: Ear/Hearing: Hearing tests, Hearing loss, Otitis externa, Otitis media, Trauma, Meniere’s disease, Mastoidectomy – perioperative care, Impacted cerumen & Cochlear implant
Correct Answer: A
Rationale: The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care.
B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site.
C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider.
D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation.
E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more