Nokea
Which client(s) would be best to assign to an experienced nurse in an ambulatory eye surgery center? (Choose all that apply.)
- A. A client who needs post-operative instructions for cataract surgery.
- B. A client who needs an eye-pad and a metal shield applied.
- C. A client who needs home health referral for dressing changes and eye drops.
- D. A client who needs teaching about self-administration of eye drops.
Correct Answer: A
Rationale: Clients requiring complex post-operative instructions, such as those for cataract surgery, benefit most from the expertise of an experienced nurse.
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A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
18. Melatonin’s use is based on scientific evidence. The patient with which problem would benefit from melatonin?
- A. Sleep problems
- B. Mild depression
- C. High cholesterol
- D. Benign prostatic hyperplasia
Correct Answer: A
Rationale: Melatonin is scientifically supported for addressing sleep problems (option A), such as insomnia or jet lag.
Match the descriptions to the stages of sleep. Some descriptions may have more than one stage and some stages may be used more than once.
- A. Brain waves resemble wakefulness
- B. Deepest sleep, lasting 20 to 40 minutes
- C. Associated with specific EEG waveforms
- D. Most vivid dreaming occurs
Correct Answer: D
Rationale: The correct answer is D (REM). REM sleep is characterized by brain waves resembling wakefulness and vivid dreaming. The deepest sleep (B) corresponds to NREM Stage 3, while specific EEG waveforms (C) are associated with all stages.
During the rehabilitative phase following his cerebrovascular accident, Mr. K. is taught measures to relieve or prevent constipation. Which of these statements indicates that Mr. K. needs further health teaching?
- A. I eat whole-wheat bread with my meals.'
- B. I eat fruit three times a day.'
- C. I don't drink fluids after 4 P.M.'
- D. I don't like to take enemas.'
Correct Answer: C
Rationale: Restricting fluid intake after 4 P.M. can contribute to dehydration and constipation, making this statement indicative of the need for further education on proper hydration practices.
A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?
- A. Administer IV fluids as prescribed by the physician.
- B. Provide straws and offer fluids between meals.
- C. Develop plan for added fluid intake over 24 hours.
- D. Teach family members to assist client with fluid intake.
Correct Answer: B
Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.