Nokea
Which nursing interventions are included in the post-operative care of the client following the repair of a retinal detachment with instillation of silicone oil?
- A. Placing the client in a prone position
- B. Maintaining strict bed rest for 24 hours
- C. Offering a clear liquid diet
- D. Instructing the client to keep his head bowed when sitting upright
- E. Applying an eye patch to protect the affected eye from light
Correct Answer: A, D, E
Rationale: Post-retinal detachment with silicone oil requires prone positioning (A) to keep oil against the retina, head bowed when upright (D) to maintain oil placement, and an eye patch (E) to reduce light exposure. Bed rest (B) is not strict, and diet (C) progresses as tolerated.
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The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 900 mL/24 hr
- B. 1300 mL/24 hr
- C. 1600 mL/24 hr
- D. 2000 mL/24 hr
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.
The client is prescribed prednisone for an acute exacerbation of lupus. Which side effect should the nurse monitor for?
- A. Hypoglycemia
- B. Weight loss
- C. Hypertension
- D. Bradycardia
Correct Answer: C
Rationale: Prednisone, a corticosteroid, can cause hypertension due to sodium retention and vasoconstriction. Hyperglycemia (not hypoglycemia), weight gain, and tachycardia are more likely than weight loss or bradycardia.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which vital sign change is most characteristic?
- A. Fever
- B. Tachycardia
- C. Hypotension
- D. All of the above
Correct Answer: A
Rationale: Fever is the most characteristic vital sign change in postpartum endometritis reflecting the underlying uterine infection. Tachycardia and hypotension occur only in severe cases.
On assessment, the nurse learns that a chronic paranoid schizophrenic has been taking 'the blue pill' (haloperidol) in the morning and evening, and 'the white pill' (benztropine) right before bedtime. The nurse might suggest to the client that she try:
- A. Doubling the daily dose of benztropine
- B. Decreasing the haloperidol dosage for a few days
- C. Taking the benztropine in the morning
- D. Taking her medication with food or milk
Correct Answer: C
Rationale: Suggesting that a client increase a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. To suggest that a client decrease a medication dosage is an inappropriate (and illegal) nursing action. This action requires a physician's order. This response is an appropriate independent nursing action. Because motor restlessness can also be a side effect of cogentin, the nurse may suggest that the client try taking the drug early in the day rather than at bedtime. Certain medications can cause gastric irritation and may be taken with food or milk to prevent this side effect.
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
- A. Examine the 4 year old first.
- B. Provide time for play and becoming acquainted.
- C. Have the mother leave the room with one child, and examine the other child privately.
- D. Examine painful areas first to get them 'over with.'
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.