What instruction should the nurse include in the discharge teaching plan of a client who had a
cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avo
...
What instruction should the nurse include in the discharge teaching plan of a client who had a
cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
ANS: B
3 of 55
A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of
breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement
first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
ANS: A
4 0f 55
An elder male client tells the nurse that he is loosing sleep because he has to get up several times at
night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel
like his bladder is ever completely empty. Which intervention should the nurse implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
ANS: C
5 of 55
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI)
Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory
value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
ANS: D
6 of 55
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of
packed red blood cell. When notifying the healthcare provider what information should the nurse
provide first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
ANS: A
7 of 55
An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While
hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what
important aspect regarding his medication therapy should the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month
d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma
ANS: C
8 of 55
A client subjective data includes dysuria, urgency, and urinary frequency. What action should the
nurse implement next?
a.collect a clean catch specimen
b.palpate the suprapubic region
c.instruct to wipe from front to
back
d.inquire about recent sexual activity
ANS: A
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