Nokea
The nurse would teach a male JOB client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. I will wash my hands before instilling eye medications.'
- B. I will wear sunglasses when going outside.'
- C. I will wear an eye patch for the first 3 postoperative days.'
- D. I will maintain the sterility of the eye medications.'
Correct Answer: C
Rationale: Eye patches are typically worn during sleep or naps, not constantly for 3 days, indicating a need for further teaching. The other options are correct preventive measures.
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A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate medical attention.
A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:
- A. Avoid heavy lifting
- B. Eat large meals
- C. Sleep flat in bed
- D. Increase spicy food intake
Correct Answer: A
Rationale: Heavy lifting increases abdominal pressure, worsening hiatal hernia symptoms. Small meals, sleeping upright, and avoiding spicy foods are also recommended.
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.
A new mother tells the nurse that she is getting a new microwave so that her husband can help prepare the baby's feedings. The nurse should:
- A. Explain that a microwave should never be used to warm the baby's bottles.
- B. Tell the mother that microwaving is the best way to prevent bacteria in the formula.
- C. Tell the mother to shake the bottle vigorously for one minute after warming in the microwave.
- D. Instruct the parents to always leave the top of the bottle open while microwaving so heat can escape.
Correct Answer: A
Rationale: Microwaving baby bottles can cause uneven heating, leading to burns, so it should be avoided; warming under running water or in a bottle warmer is safer.
The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?
- A. Mosquitoes
- B. Blood transfusions
- C. Transplanted organs
- D. Birds
- E. Horses
Correct Answer: A, B, C
Rationale: West Nile virus is transmitted by mosquitoes (A), blood transfusions (B), and organ transplants (C). Birds (D) and horses (E) are hosts but not direct vectors to humans.