Med Surg 2 Unit 4 Homework

A nurse is an urgent care center is collecting data from a client who reports taking an excessive amount of aspirin. Which of the following findings should the nurse identify as an indication of salicylicm? A.Tinnitus B.Joint pain C.Diuresis D.Respiratory depression

A. Tinnitus' A client can develop salicylism when aspirin levels exceed therapeutic levels. Clinical manifestations include tinnitus, sweating, headache, dizziness, and hyperventilation.

A nurse is assisting with the plan of care for a client who is postoperative following repair of a detached retina. Which of the following interventions should the nurse include in the plan of care? a. Apply an eye shield during naps and at bedtime. b. Encourage the client to cough frequently. c. Keep both eyes bandaged. d. Wipe the affected eye from the outer to the inner canthus with a moist wash cloth.

Apply an eye shield during naps and bedtime The nurse should apply an eye shield when the client takes a nap and at bedtime to protect the affected eye from accidental injury while sleeping.

Before administering client medications, the nurse must identify the client. Which of the following methods of identification should the nurse use? a. Ask the client's full name and date of birth. b. Verify the client's room number. c. Check the client's name on the medication administration record (MAR). d. Ask a family member to verify the client's identity.

Ask the client's full name and date of birth The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take? a. Return the medication to the stock for future use. b. Report the discrepancy immediately. c. Administer the medication to other clients to avoid waste. d. Independently dispose of the remaining medication.

B. report the discrepancy immediately Because this medication is a controlled substance, the nurse should remove the medication from the client's bedside and report the incident according to the facility's policy. After that, she should dispose of it with another nurse witnessing the discard.

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (SATA) Client's ability to pay for the consented surgical procedure Client's ability to read the consent form Disclosure of the treatment is provided Client understands the surgical procedure Voluntary consent is given

Disclosure of the treatment is provided Client understands the surgical procedure Voluntary consent is given

A nurse observes two assistive personnel (AP) arguing over who should go on break first. The nurse interrupts the conversation and states one AP can take break now, but the other AP will get to take an early lunch. Which of the following types of conflict management is the nurse demonstrating.

Compromising The nurse is demonstrating compromising to resolve the conflict between the two APs. Compromising is when all parties involved are willing to give up something for the resolution of the conflict.

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching? A. Tonometry is performed to evaluate peripheral vision." B. "This test will diagnose the type of your glaucoma." C. "Tonometry will allow inspection of the optic disc for signs of degeneration." D."This test will measure the intraocular pressure of the eye."

D. this test will measure the intraocular pressure of the eye. A tonometry examination provides a precise and simple way to measure intraocular pressure. This is a component of a comprehensive eye examination and is crucial for clients who have glaucoma or who are at high risk for developing intraocular hypertension.

A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? A. "I will take a stool softener until my eye is healed." B. "I will expect to have moderately severe pain for 1-2 days." C. "I will refrain from cooking for 1 week." D. "I will bend at the waist to tie my shoes."

I will take a stool softener until my eye is healed The client should avoid straining during bowel movements to prevent an increase in intraocular pressure.

A nurse is providing discharge instructions for a client following outpatient cataract surgery with insertion of an intraocular lens. Which of the following should the nurse include? a. Eye drops can cause halos to appear around lights. b. Lying on the unaffected side can prevent complications. c. Surgery can cause temporary reduced visual acuity. d. Warm compresses over the surgical eye can reduce pain.

Lying on the unaffected side can prevent complications The nurse should include information about ways to prevent intraocular pressure, which includes preventing straining or vomiting and lying on the unaffected side when in bed.

A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care? a. "Remain on bed rest for at least 2 days." b. "Rest in semi-Fowler's position." c. "Deep-breathe and cough four times a day." d. "Lie on the side of the surgery when in bed."

Rest in semi-fowlers position The client should rest in a semi-fowlers position to prevent increasing intraocular pressure

A nurse is caring for a client who has dementia and is scheduled for a procedure. Which of the following individuals should the nurse request to sign the client's informed consent? a. The client's sister, who assists with finances b. The client, who has advance directives c. The client's daughter, who is the primary caregiver d. The client's son, who has a durable power of attorney

The client's son, who has a durable power of attorney A durable power of attorney for health care is a legal document that designates an individual authorized to make health care decisions for a client who is unable. The client's son has the legal authority to make decisions pertaining to the client's medical care. The son should be familiar with the client's wishes.

A nurse is assisting with the preparation of an instructional plan for a client who has vision loss. Which of the following strategies should the nurse include in the pain?

Use of auditory or tactile materials The use of auditory or tactile materials bypasses the need to see or read. Therefore, it is an appropriate intervention for clients who have vision loss.

A nurse is reinforcing teaching with a client who has glaucoma. Which of the following statements should the nurse make? a. "Without treatment, glaucoma can cause blindness." b. "Double vision is a common symptom of glaucoma." c. "Glaucoma results from inadequate production of fluid within the eye." d. "You will need to treat glaucoma by instilling eye drops once a week."

Without treatment, glaucoma can cause blindness. The nurse should explain that without treatment, glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to see first? a. A client who wants a bath b. A client who needs a referral for home health services c, A client who requests pain medication d. A client who asks to review the instructions he received about his new prescription

a client who requests pain medication When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority action is to assess the client requesting pain medication. Untreated pain can result in physiological and psychological effects including hypertension, shallow respirations, disturbed sleep, depression, anxiety, and fear.

A charge nurse in an acute facility revives a client request not o have a particular assistive personnel (AP) care for her. Which of the following actions should the charge nurse take? a. Document the issue on an incident report. b. Address the concern with the assigned nurse. c. Explain to the client the AP was having a bad day. d. Notify the human resources department.

address the concern with the assigned nurse The charge nurse should address the concern with the assigned nurse to help resolve the issue by adjusting the assignments and then discussing the issue with the AP that cared for the client.

A nurse os reinforcing teaching with a class of newly licensed nurses about preparing clients for surgery. Which of the following instructions should the nurse include in the teaching? a. Secure a client's body piercings with tape. b. Allow a client to leave dentures in his mouth. c. Remove a client's hearing aid. d. Ask a client to remove contact lenses.

ask a client to remove contact lenses the nurse should ask a client to remove contact lenses to prevent damage to the client's eyes during surgery

A nurse collecting data from a client who has Meniere's disease? Which of the following is an expected finding for this client? a. Bilateral ear pain b. Gradual hearing loss c. Impacted cerumen d. Retracted eardrum

b. gradual hearing loss An expected finding for a client who has Meniere's disease is tinnitus and gradual loss of hearing in one ear. Some clients also have hearing loss in both ears.

A nurse is collecting data from a client who had open-angle glaucoma. Which of the following findings should the nurse expect? a. Loss of peripheral vision b. Headache c. Halos around lights d. Discomfort in the eyes

loss of peripheral vision The nurse should expect to find the client experiencing a gradual loss of peripheral vision with a narrowing of the visual field with open-angle glaucoma.

A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? a. Avoid bending at the waist. b. Remove the eye shield at bedtime. c. Limit the use of laxatives if constipated. d. Seeing flashes of light is an expected finding following extraction.

avoid bending at the waist The nurse should reinforce that the client should avoid bending at the waist as this increases intraocular pressure; the client should be instructed to flex the knees and crouch instead.

A nurse is reinforcing discharge teaching with a client who is postoperative following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take a dose of aspirin if I have pain in the area of my eyebrow." b. "I can pick up a sack of groceries that weighs 15 pounds." c. "I can begin lying on my operative side 24 hours after my surgical procedure." d. "I will bend at my knees if I need to pick something up off of the floor."

I will bend at my knees if I need to pick something up off of the floor. The client should avoid bending at the waist because this increases intraocular pressure. Bending at the knees is the correct way to pick something up off of the floor.

A nurse is caring for a client who has a hearing loss in her left ear. Which of the following nursing actions should the nurse take? a. Over articulate words to improve client understanding. b. Change voice volume during each sentence. c. Minimize background noise to decrease distractions. d. Sit in a chair to one side of the client.

Minimize background noise to decrease distractions Decreasing background noise during conversations can increase the client's ability to hear what the nurse is saying.

A nurse is reinforcing preoperative teaching with a client who is scheduled for retinal detachment repair. Which of the following instructions should the nurse include in the teaching? a. Keep both eyes patched. b. Restrict head movement. c. Lie down as much as possible. d. Apply cool compresses.

Restrict head movement The client should restrict head and eye movement to prevent further detachment prior to surgery

A nurse is caring for a client who just had cataract surgery. Which of the following comments from the client should the nurse report to the provider? a. "The bright light in this room is really bothering me." b. "My eye really itches, but I'm trying not to rub it." c. "It's really hard to see with a patch on one eye." d. "I need something for the horrible pain in my eye."

I need something for the horrible pain in my eye. Following cataract surgery, the client should expect only mild pain, and should immediately report any severe pain in the eye. Severe eye pain after surgery might indicate an increase in intraocular pressure, which can disrupt the surgical site and cause permanent damage to the eye if the client does not receive treatment promptly.

A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? a. "When my vision improves, I will be able to stop taking the eye drops." b. "If I forget to take my eye drops, I should wait until the next time they are due." c. "I should call the clinic before taking any over-the-counter medications." d. "Every two years I will need to have my vision checked by an eye doctor."

I should call the clinic before taking any over-the-counter medications Taking over-the-counter medications that dilate the pupil could cause the client who has chronic open angle glaucoma to experience an increase in intraocular pressure. The nurse should instruct the client to always check with the provider before using over-the-counter medications.

A nurse is reinforcing teaching with a client who has chronic open angle glaucoma. The client has been prescribed pilocarpine ophthalmic solution. Which of the following statements by the client demonstrates an understanding of the teaching? a. "I'll use the eye drops once daily first thing in the morning." b. "I'll be able to see better at night while taking this medication." c. "I should expect to have blurred vision for up to two hours after using this medication." d. "Since these drops go right into my eyes, I won't experience medication effects in other parts of my body."

I should expect to have blurred vision for up to two hours after using this medication Clients who use pilocarpine experience blurred vision for 1 to 2 hr after use, and should time activities accordingly.

A nurse is reinforcing discharge teaching with a client who I postoperative following a cataract extraction from the left eye with a placement of an intraocular lens implant. Which of the following statements by the client indicates a need for further teaching. a. "My eye may feel a little itchy for a while after surgery, but that's normal." b. "I may have white drainage around my eye but it's not necessary to notify my surgeon about it." c. "I will change my eye patch dressing every other day." d. "My vision might be better by tomorrow."

I will change my eye patch dressing every other day. The client should change the eye patch dressing at least every day

A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following action should the nurse take? a. Irrigate the eye daily with 0.9% sodium chloride irrigation solution. b. Dim the lights in the room. c. Instill ophthalmic ointment into the lower lid. d. Keep the client off her left side.

Instill ophthalmic ointment into the lower lid To help prevent drying, the nurse should use artificial tears or ophthalmic ointment to keep the eye moist.

A nurse is contributing to the plan of care for a client who has labyrinthitis. Which of the following interventions should the nurse include in the plan? a. Limit fluid intake. b. Monitor client's cardinal fields of vision. c. Encourage ambulation. d. Ensure the room is brightly lit.

Monitor client's cardinal fields of vision The nurse should assess for nystagmus, abnormal jerking movements of the eyes, by evaluating the six cardinal fields of gaze. Nystagmus is a manifestation of labyrinthitis.

A nurse is caring for the client who has Meniere's disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make? A. "You are free to move around your room as you wish, but you should avoid the hallways." B."You are on strict bed rest and must not be up." C."Please call for assistance when you wish to get out of bed." D."Why would we not allow you to walk if you wanted?"

Please call for assistant when you wish to get out of bed this is an appropriate response by the nurse. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease, which can increase the client's risk of falls when ambulating.

A nurse at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching? a. Feed the client soft foods for several days. b. Position the client on the affected side to rest. c. The client should remain in bed for 3 days. d. The client should wear dark glasses while outdoors.

The client should wear dark glasses while outdoors. Following surgical removal of a cataract, the nurse should instruct the client and partner to wear sunglasses when outside until pupil reaction returns.

A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication? Nonverbal communication conveys less truth than what the client states verbally. The client's sociocultural background influences nonverbal communication. Nonverbal communication is a poor reflection of what the client feels. The client enacts nonverbal communication consciously.

The client's sociocultural background influences nonverbal communication Sociocultural background has a major influence on what a client's nonverbal behavior means.

A nurse is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take? a. Set aside any controlled substances the nurse plans to give during her shift. b. Verify that the amounts of each medication she counts match the amounts on the inventory record. c. Co-sign any notations of wasting controlled substances on the previous shift. d. Discard any partial doses she finds in the cabinet in the sharps container.

Verify that the amount of each medication she counts match the amounts on the inventory record. If the amounts available do not match the amounts on the inventory record after subtracting what the nurses administered during the previous shift and adding any medications the nurses added to the cabinet, the nurse must address and reconcile the count.

A nurse is preparing to administer ofloxacin otic drops to an adult client who has otitis extreme. Which of the following actions should the nurse take? a. Hold the dropper against the ear canal while instilling the medication. b. Apply gentle pressure with a finger to the tragus of the ear. c. Chill the medication prior to administration. d. Straighten the external auditory canal by pulling it down and back.

apply gentle pressure with a finger to the trigs of the ear Applying gentle pressure with a finger to the tragus of the ear after administration will facilitate movement of the fluid down the ear canal.

A nurse is caring for a client who is unconscious and has lost the corneal reflex. Which of the following actions should the nurse take? a. Keep the client's room darkened. b. Place a patch over the eye. c. Apply a warm saline compress to the eye. d. Cleanse the eye with a mild soap.

place a patch over the eye If the corneal reflex is lost, the nurse should place an eye shield or patch over the client's eye to prevent dryness and irritation.

A nurse is reinforcing preoperative teaching with a client who is scheduled for cataract surgery. Which of the following statements should the nurse make? a. "You should report bloodshot eyes on the day of surgery." b. "You should apply warm compresses to the eye 3 times daily." c. "You should expect brow pain for 3 days after the procedure." d. "You should expect your vision to improve within 2 weeks of the surgery."

you should expect your vision to improve within 2 weeks of surgery vision should improve within 2 weeks of the operation and be fully recovered within 3 months