Med-Surg 455

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority? A. Notify the surgeon. B. Instill an antibiotic solution in both eyes. C. Clean eye from inner to outer canthus. D. Apply a non-pressure patch to the affected eye.

A. Notify the surgeon.

The nurse is assessing a client with acute mastoiditis. Which of the following manifestations should the nurse expect? A. Swelling behind the affected ear B. Facial drooping on the affected side C. Nystagmus on the affected side D. Pearly grey color of the affected eardrum

A. Swelling behind the affected ear

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet

B. MRI of the chest

The nurse is providing discharge teaching for the client who is postoperative following a cataract surgery with intra-ocular lens implant. Which of the following statements by the client indicates an understanding of the teaching? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet." D. "I will take aspirin to relieve my pain."

B. "I will avoid bending over."

The nurse is providing discharge teaching for the client who has a scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. You can expect your vision to return immediately after the procedure." B. "You should avoid reading for one week." C. "You can remove the eye shield while you are sleeping." D. "You should not lift objects that weigh more than 30 pounds."

B. "You should avoid reading for one week."

You are discharging a patient with Meniere's disease who is experiencing severe vertigo. Which instruction would the nurse give to assist in controlling vertigo? A. Increase fluid intake to 3000 ml a day B. Avoid sudden head movements C. Lie still and watch the television D. Increase sodium in the diet

B. Avoid sudden head movements

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise

B. Dyspnea

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the client's ability to sleep. D. It reduces the client's blood pressure.

B. It facilitates the client's deep breathing.

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

C. Irregular

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority? A. Airway management B. Amiodarone administration C. Defibrillation D. Epinephrine administration

C. Defibrillation

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? A. Pacemaker spikes after each QRS complex B. Pacemaker spikes before each P wave C. Pacemaker spikes before each QRS complex D. Pacemaker spikes with each T wave

C. Pacemaker spikes before each QRS complex

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate? A. Brachial pulse in the left arm B. Brachial pulse in the right arm C. Radial pulse in the left arm D. Radial pulse in the right arm

C. Radial pulse in the left arm

A nurse is assessing a client with a new diagnosis of acute-angle closure glaucoma. The nurse should anticipate that the client will report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

C. Severe eye pain

A client who experienced a myocardial infarction (MI) 48 hours ago is most at risk for developing: A. cardiogenic shock B. heart failure C. arrhythmias D. pericarditis

C. arrhythmias

The nurse is caring for four clients with eye concerns. Which client, who has a family history of an eye disorder, does the nurse identify at risk for increased intraocular pressure (IOP)? A. Client with family history of diabetic retinopathy B. Client with family history of anisocoria C. Client with family history of presbyopia D. Client with family history of glaucoma

D. Client with family history of glaucoma

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? A. Speak using his usual tone of voice. B. Stand directly in front of the client. C. Rephrase statements the client does not hear. D. Determine if the client uses hearing aids.

D. Determine if the client uses hearing aids.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Differences between oral and axillary temperatures. C. Differences in upper and lower lung sounds. D. Different apical and radial pulses.

D. Different apical and radial pulses.

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation

D. To reduce the risk of stroke in clients who have atrial fibrillation