Nursing Elites

1. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Use direct lighting when reading for 6 weeks.
• D. Irrigate the conjunctiva with saline before applying ointment.

Correct answer: A

Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.

2. The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?

• A. Platelet count and red blood cell count.
• B. White blood cell count and sputum culture.
• C. Hemoglobin A1c and glucose tolerance test.
• D. Arterial blood gases and serum electrolytes.

Correct answer: B

Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.

3. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows has disappeared, and that her eyes are puffy. What follow-up question is best for the nurse to ask?

• A. Have you noticed any changes in your fingernails?
• B. Have you had any changes in weight or energy levels?
• C. Do you have a family history of thyroid problems?
• D. Have you had recent cold intolerance or unusual fatigue?

Correct answer: D

Rationale: The correct answer is D. Cold intolerance, fatigue, and other changes may indicate hypothyroidism, which could explain the hair and eyebrow loss, and puffy eyes. Choices A, B, and C are less relevant in this context and do not directly address the symptoms presented by the client.

4. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

5. A client with chronic kidney disease is admitted with complaints of fatigue and swelling in the lower extremities. What laboratory finding is most important for the nurse to report?

• A. Serum creatinine level of 2.0 mg/dL.
• B. Hemoglobin level of 8 g/dL.
• C. Potassium level of 5.6 mEq/L.
• D. Blood urea nitrogen (BUN) level of 25 mg/dL.

Correct answer: B

Rationale: The correct answer is B. A hemoglobin level of 8 g/dL suggests anemia, which commonly occurs in clients with chronic kidney disease and requires prompt intervention. Reporting this finding is crucial to address the anemic condition. Choices A, C, and D are important in the context of chronic kidney disease but do not directly relate to the symptoms of fatigue and swelling in the lower extremities described in the scenario.

Similar Questions