hesi exit (adult health)
The client is receiving an eye drop and an eye ointment to the right eye. Which action should the nurse take?
Administer the eye drop first, followed by the eye ointment. When an eye drop and an eye ointment is scheduled to be administered at the same time, the eye drop is administered first.
A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome?
Bradycardia and confusion TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply.
Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks. If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing on the peritoneal dialysis system is also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open.
The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis?
Diabetes mellitus Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.
The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?
Report the finding to the registered nurse (RN). If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage
A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?
The medication causes the pupil to constrict and will lower the pressure in the eye Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork
Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?
Atropine sulfate Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are ß-blockers.
The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?
Atropine sulfate,a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.
The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom?
Decreased force in the stream of urine Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client may then develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.
A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?
On bed rest in a semi-Fowler's position A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.
The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply.
Vision may be cloudy Complaints of a burst of black spots or floaters Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy.