Nokea
To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
- A. Lying supine.
- B. Coughing.
- C. Deep breathing.
- D. Ambulation.
Correct Answer: B
Rationale: Coughing increases intraocular pressure by causing a Valsalva maneuver, which can strain the surgical site and lead to complications like hemorrhage or wound dehiscence.
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A client with a lumbar spinal fusion is preparing for discharge. Which activity should the nurse advise the client to avoid?
- A. Walking short distances daily.
- B. Lifting objects heavier than 10 pounds.
- C. Sleeping on a firm mattress.
- D. Using a recliner for sitting.
Correct Answer: B
Rationale: Lifting heavy objects can strain the surgical site, delaying healing post-spinal fusion.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
- A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
- B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
- C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
- D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.
The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse seems the client's identification and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next?
- A. Contact the pharmacist immediately to check the order and the barcode label for accuracy.
- B. Administer the medication now, knowing the medication is labeled and the client is identified.
- C. Report the problem to the information technology team to have the barcode system recalibrated.
- D. Ask another nurse to verify the medication and the client so the medication can be given now.
Correct Answer: A
Rationale: A barcode verification failure indicates a potential error, requiring immediate pharmacist consultation to confirm the order and ensure patient safety.
The nurse should assess a client with thrombocytopenia who has developed a hemorrhage for which of the following?
- A. Tachycardia.
- B. Bradycardia.
- C. Decreased urine output.
- D. Hypotension.
Correct Answer: A
Rationale: Hemorrhage in a client with thrombocytopenia can lead to hypovolemia, causing tachycardia as the heart compensates for decreased blood volume. Bradycardia is not typical, and while decreased urine output and hypotension may occur later, tachycardia is an earlier and more immediate sign.
A client who has been diagnosed with tuberculosis has been placed on drug therapy. The medication regimen includes rifampin (Rifadin). Which of the following instructions should the nurse include in the client's teaching plan related to the potential adverse effects of rifampin? Select all that apply.
- A. Mailing eye examinations every 6 months.
- B. Maintaining follow-up monitoring of liver enzymes.
- C. Decreasing protein intake in the diet.
- D. Avoiding alcohol intake.
- E. The urine may have an orange color.
Correct Answer: B,D,E
Rationale: Rifampin requires liver enzyme monitoring (B) and alcohol avoidance (D) due to hepatotoxicity risk. Orange urine (E) is a harmless side effect. Eye exams and reduced protein intake are not indicated.