Nokea
Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
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The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
The nurse transfers a client who received fentanyl 50 mcg IV push 10 minutes ago from the bed to a chair when the client becomes dizzy and falls into the chair. Which of the following actions would be appropriate for the nurse to take?
- A. Administer prescribed naloxone
- B. Assist the client back to bed
- C. Call a code blue
- D. Assess the client's vital signs
Correct Answer: B
Rationale: Dizziness after fentanyl administration suggests orthostatic hypotension; assisting the client back to bed ensures safety.
A client post-inguinal herniorrhaphy reports scrotal swelling 24 hours after surgery. Which action should the nurse take first?
- A. Apply a warm compress to the scrotum.
- B. Notify the surgeon.
- C. Elevate the scrotum and apply ice.
- D. Administer a diuretic as ordered.
Correct Answer: C
Rationale: Elevating the scrotum and applying ice is the first action to reduce scrotal swelling post-inguinal herniorrhaphy, a common postoperative finding. Warm compresses may worsen swelling, notification is needed if swelling persists, and diuretics are not indicated. CN: Physiological adaptation; CL: Synthesize
A client with renal calculi reports sudden cessation of pain. The nurse should:
- A. Strain all urine.
- B. Administer analgesics.
- C. Check vital signs.
- D. Encourage bed rest.
Correct Answer: A
Rationale: Sudden pain cessation may indicate stone passage; straining urine confirms this.