Nokea
Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment after applying eye drops.
- C. Light housekeeping is safe to do, but avoid heavy lifting.
- D. Refrain from sexual activities until follow-up appointment.
Correct Answer: C
Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.
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What is the most critical initial intervention for a client who is actively seizing?
- A. Restrain the client to prevent injury
- B. Insert an oral airway
- C. Turn the client to the side
- D. Apply soft restraints to the wrists
Correct Answer: C
Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.
An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
- A. Alcohol
- B. Mineral oil
- C. Calamine
- D. A&D ointment
Correct Answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
- A. Weigh yourself daily and report a gain of 2 pounds in 24 hours
- B. Increase fluid intake to stay hydrated
- C. Consume a high-sodium diet to retain fluids
- D. Engage in vigorous exercise daily
Correct Answer: A
Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention. Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure. Choice C is incorrect as a high-sodium diet can worsen fluid retention. Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.
Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?
- A. Keep the arm and shoulder of the affected side immobile at all times.
- B. Encourage the client to breathe deeply and cough at frequent intervals.
- C. Maintain the pleura vac slightly above the chest level.
- D. Ensure there is no fluctuation in the water seal.
Correct Answer: B
Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
- A. Osmolarity
- B. Glucose
- C. Albumin
- D. Platelets
Correct Answer: B
Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.