Nokea
A client after right cataract surgery.
The nurse would intervene in which of the following situations?
- A. Client is in the supine position.
- B. The head of the bed is elevated 30°.
- C. The client is lying on her right side.
- D. An eye shield is over the right eye.
Correct Answer: C
Rationale: Strategy: 'Nurse would intervene' indicates an incorrect action. (1) appropriate position (2) decreases swelling and pain (3) correct-client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate
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The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
- A. Position the infant in the car seat as positioned.
- B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
- C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
- D. Place the car seat in the back seat and position the infant appropriately.
Correct Answer: B
Rationale: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.
The nurse is to suction a client. What action is essential prior to inserting the suction catheter?
- A. Clear the mouth and throat of secretions.
- B. Lower the head of the bed.
- C. Oxygenate the client.
- D. Check the suction pressure.
Correct Answer: C
Rationale: Pre-oxygenation prevents hypoxia during suctioning, a critical step. Clearing secretions, lowering the bed, or checking pressure are secondary.
During a prenatal visit, a client states: 'I have been very nauseated during my first trimester, and I don't understand the reason.' Which of the following responses by the nurse is BEST?
- A. You are nauseated because of the fatigue you are feeling.'
- B. The nausea is due an increase in the basal metabolic rate.'
- C. The nausea is caused by a secondary elevation in the hormones produced by the endocrine system.'
- D. If you eat different kinds of foods, you won't be nauseated.'
Correct Answer: C
Rationale: during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system
A 28-year-old primigravida with pregestational diabetes visits the clinic 6 weeks gestation. Which of the following statements indicates that she understands the nurse's teaching regarding her insulin needs during pregnancy?
- A. As the baby grows, I will need more insulin because the baby will not be able to make insulin.
- B. Changes in hormone levels will make my body more resistant to insulin, so I will need more insulin as the pregnancy progresses.
- C. As the baby grows, I will need less insulin because the baby uses up any extra glucose.
- D. If I maintain an adequate balance of diet and exercise, my insulin requirements will be the same.
Correct Answer: B
Rationale: Pregnancy hormones increase insulin resistance, requiring more insulin as pregnancy progresses in diabetic patients. Other statements are incorrect regarding insulin dynamics.