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 is administering a new medication to a client. What is the priority action before administering the drug?

• A. Verify the client's allergies
• B. Check the client's blood pressure
• C. Assess the client's pain level
• D. Provide client education on the medication

Correct answer: A

Rationale: Verifying the client's allergies is the priority action before administering any medication. It is crucial to identify any known allergies to prevent potential allergic reactions, which can be severe and life-threatening. Checking the client's blood pressure, assessing pain levels, and providing education on the medication are important aspects of client care but verifying allergies is essential for ensuring the safety of the client.

3. A 5-week-old infant with hypertrophic pyloric stenosis has developed projectile vomiting over the last two weeks. Which intervention should the nurse plan to implement?

• A. Instruct the mother to give sugar water only.
• B. Offer the infant oral rehydration every 2 hours.
• C. Provide Pedialyte feedings via nasogastric tube.
• D. Maintain intravenous fluid therapy.

Correct answer: D

Rationale: The correct intervention for a 5-week-old infant with hypertrophic pyloric stenosis presenting with projectile vomiting is to maintain intravenous fluid therapy. This is essential to maintain hydration before surgery. Instructing the mother to give sugar water only (Choice A) is inadequate and does not address the need for proper hydration. Offering oral rehydration every 2 hours (Choice B) may not be effective in cases of severe vomiting and could lead to further fluid loss. Providing Pedialyte feedings via nasogastric tube (Choice C) is an option, but in severe cases, intravenous fluid therapy is more effective in ensuring hydration and electrolyte balance.

4. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?

• A. Urine output increases to 50 mL/hour
• B. Client reports feeling more thirsty
• C. Blood pressure decreases from 120/80 to 110/70
• D. Heart rate increases from 80 to 100 beats per minute

Correct answer: A

Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.

5. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6 hours are prescribed. What actions should the nurse include in this client's plan of care?

• A. Teach subcutaneous injection technique, site rotation, and insulin management
• B. Coordinate carbohydrate-controlled meals at consistent times and intervals
• C. Review with the client proper foot care and prevention of injury
• D. All of the above

Correct answer: D

Rationale: Effective diabetes management involves comprehensive care, including proper foot care, insulin administration technique, and maintaining carbohydrate consistency with meals. All of these interventions are critical in reducing hyperglycemic episodes and managing diabetes.

Similar Questions