Eyes & Ears
A nurse is caring for a patient after cataract surgery. Which of the following instructions should the nurse provide to the patient to prevent complications?
A. Avoid bending over at the waist.
B. Sleep on the operated side.
C. Rub the operated eye gently if it itches.
D. Wear protective eyewear only during the day.
Answer: A. Avoid bending over at the waist.
Rationale: Patients should avoid bending over at the waist to prevent increasing intraocular pressure after cataract surgery. They should also avoid sleeping on the operated side and rubbing the eye. Protective eyewear should be worn as instructed, usually both day and night initially, to protect the eye from injury.
A nurse is assessing a patient with suspected gout. Which of the following symptoms is characteristic of this condition?
A. Bilateral joint pain in the knees
B. Pain and swelling in the great toe
C. Gradual onset of back pain
D. Symmetrical joint involvement
Answer: B. Pain and swelling in the great toe
Rationale: Gout often presents with sudden, severe pain and swelling in the great toe, known as podagra. It typically affects one joint at a time and is not symmetrical. Bilateral knee pain and gradual onset of back pain are not typical of gout.
A nurse is teaching a patient with HIV about antiretroviral therapy (ART). Which of the following statements should the nurse include in the teaching?
A. “You can stop taking your medication when your viral load is undetectable.”
B. “Take your medications at the same time every day.”
C. “You can skip doses if you feel fine.”
D. “ART will cure your HIV infection.”
Answer: B. “Take your medications at the same time every day.”
Rationale: Consistency in taking antiretroviral therapy at the same time every day is crucial for maintaining viral suppression and preventing resistance. ART does not cure HIV, and skipping doses can lead to drug resistance. Patients should continue taking their medication even when their viral load is undetectable.
A nurse is caring for a patient with gastroesophageal reflux disease (GERD). Which of the following instructions should the nurse include in the teaching plan?
A. “Lie down immediately after meals.”
B. “Avoid eating spicy foods.”
C. “Consume large meals throughout the day.”
D. “Drink caffeinated beverages in moderation.”
Answer: B. “Avoid eating spicy foods.”
Rationale: Spicy foods can exacerbate symptoms of GERD by increasing gastric acid production and should be avoided. Lying down immediately after meals can worsen reflux symptoms. Consuming large meals can increase intra-abdominal pressure and contribute to reflux. Caffeinated beverages should be limited because caffeine can relax the lower esophageal sphincter, allowing gastric contents to reflux into the esophagus.
A nurse is caring for a patient who is postoperative following bowel resection. Which finding should the nurse report to the healthcare provider immediately?
A. Serous drainage on the surgical incision dressing
B. Absent bowel sounds in all quadrants
C. Pain at the surgical incision site
D. Mild abdominal distention
Answer: B. Absent bowel sounds in all quadrants
Rationale:
Absent bowel sounds in all quadrants could indicate paralytic ileus, a complication of abdominal surgery that requires immediate intervention to prevent bowel obstruction or perforation. Serous drainage, pain at the incision site, and mild abdominal distention are common postoperative findings that may not require immediate reporting unless they worsen or are accompanied by other symptoms.
A nurse is assessing a patient who reports sudden vision loss in one eye, seeing floaters, and flashes of light. The nurse should recognize these symptoms as indicative of which condition?
A. Cataracts
B. Retinal detachment
C. Glaucoma
D. Conjunctivitis
Answer: B. Retinal detachment
Rationale: Sudden vision loss, floaters, and flashes of light are classic symptoms of retinal detachment, a serious condition requiring immediate medical attention. Cataracts cause gradual vision loss, glaucoma typically causes peripheral vision loss, and conjunctivitis presents with eye redness and discharge.
A nurse is teaching a patient with fibromyalgia about management strategies. Which of the following instructions should the nurse include?
A. “Limit your physical activity to avoid fatigue.”
B. “Take a warm bath before bedtime to help relax muscles.”
C. “Increase your intake of caffeinated beverages for energy.”
D. “Avoid all dairy products and gluten.”
Answer: B. “Take a warm bath before bedtime to help relax muscles.”
Rationale: Taking a warm bath before bedtime can help relax muscles and improve sleep for patients with fibromyalgia. Patients are encouraged to engage in regular physical activity within their tolerance levels to prevent deconditioning. Caffeine should be limited as it can interfere with sleep. There is no specific need to avoid dairy products and gluten unless the patient has known sensitivities.
A patient with lymphoma is experiencing severe nausea and vomiting due to chemotherapy. Which of the following interventions should the nurse prioritize?
A. Offer clear fluids and bland foods
B. Encourage deep breathing exercises
C. Administer prescribed antiemetics
D. Provide a cool, dark environment
Answer: C. Administer prescribed antiemetics
Rationale: Administering prescribed antiemetics is the most effective intervention for managing severe nausea and vomiting in a patient receiving chemotherapy. Offering clear fluids and bland foods, encouraging deep breathing exercises, and providing a cool, dark environment can help but are secondary to antiemetic medication.
A nurse is caring for a patient with cirrhosis. Which of the following laboratory findings should the nurse expect?
A. Elevated serum albumin levels
B. Decreased serum bilirubin levels
C. Elevated ammonia levels
D. Decreased international normalized ratio (INR)
Answer: C. Elevated ammonia levels
Rationale: Cirrhosis can lead to impaired liver function, resulting in elevated ammonia levels (hyperammonemia) due to the liver’s decreased ability to metabolize ammonia. Serum albumin levels are typically decreased in cirrhosis due to impaired synthetic function. Serum bilirubin levels can be elevated due to impaired bilirubin metabolism. The INR is typically elevated due to impaired clotting factor synthesis.
A nurse is caring for a patient who is scheduled for surgery and is anxious. Which action should the nurse take to alleviate the patient’s anxiety?
A. Administer sedative medication as prescribed
B. Explain the surgical procedure in detail
C. Provide distractions such as television or music
D. Encourage the patient to talk about their feelings
Answer: D. Encourage the patient to talk about their feelings
Rationale:
Encouraging the patient to talk about their feelings allows them to express concerns and fears, which can help alleviate anxiety. Sedative medication may be used if prescribed, but addressing the patient’s emotional needs through communication is an initial non-pharmacological approach. Providing information about the surgical procedure and distractions can also help, but supporting emotional expression should be prioritized.
A nurse is reviewing the medication administration record for a patient with otitis media who has been prescribed amoxicillin. Which of the following information is most important for the nurse to confirm before administering the medication?
A. The patient’s allergy history
B. The patient’s recent dietary intake
C. The patient’s blood pressure
D. The patient’s last bowel movement
Answer: A. The patient’s allergy history
Rationale: It is most important to confirm the patient’s allergy history before administering amoxicillin, as this antibiotic can cause severe allergic reactions in patients with a penicillin allergy. Recent dietary intake, blood pressure, and last bowel movement are less relevant to the immediate safety of administering amoxicillin for otitis media.
A patient with rheumatoid arthritis is prescribed methotrexate. Which of the following instructions should the nurse include in the teaching plan regarding this medication?
A. “Take this medication on an empty stomach.”
B. “Report any signs of infection immediately.”
C. “Increase your intake of green leafy vegetables.”
D. “Avoid all physical activity to prevent joint damage.”
Answer: B. “Report any signs of infection immediately.”
Rationale: Methotrexate is an immunosuppressant, and patients taking it are at increased risk for infections, so they should report any signs of infection immediately. Methotrexate should be taken with food to decrease gastrointestinal upset. Patients on methotrexate are often advised to avoid excessive consumption of green leafy vegetables due to their high folate content, which can interfere with the medication. Physical activity should be maintained as tolerated to preserve joint function.
A nurse is caring for a patient with leukemia who is receiving chemotherapy. Which laboratory result should the nurse monitor closely to detect early signs of infection?
A. Hemoglobin level
B. Platelet count
C. White blood cell count
D. Serum creatinine
Answer: C. White blood cell count
Rationale: Monitoring the white blood cell count is crucial in patients receiving chemotherapy for leukemia because a low count can indicate neutropenia, increasing the risk of infection. Hemoglobin and platelet counts are important for other aspects of health but are not specific to detecting early signs of infection. Serum creatinine monitors kidney function.
A nurse is providing discharge instructions to a patient who has just undergone lithotripsy for renal calculi. Which of the following statements by the patient indicates understanding of the instructions?
A. “I will increase my intake of calcium-rich foods.”
B. “I will strain my urine to monitor for stone fragments.”
C. “I will take a hot bath to relieve any discomfort.”
D. “I will resume my normal physical activities immediately.”
Answer: B. “I will strain my urine to monitor for stone fragments.”
Rationale: Straining urine after lithotripsy helps monitor for the passage of stone fragments, which is important for assessing treatment effectiveness. Increasing calcium intake may contribute to stone formation, so it should be avoided or monitored. Hot baths are not recommended immediately after lithotripsy due to the risk of bleeding or discomfort. Resuming normal physical activities should be discussed with the healthcare provider based on individual recovery.
A nurse is caring for a patient immediately postoperative following orthopedic surgery. Which assessment finding requires immediate intervention?
A. Mild swelling and coolness of the affected extremity
B. Respiratory rate of 14 breaths per minute
C. Capillary refill less than 3 seconds
D. Decreased sensation distal to the surgical site
Answer: D. Decreased sensation distal to the surgical site
Rationale:
Decreased sensation distal to the surgical site could indicate compromised neurovascular status, such as nerve damage or vascular compromise, which requires immediate intervention to prevent further complications. Mild swelling and coolness, a normal respiratory rate, and normal capillary refill are expected findings postoperatively.
A patient with chronic otitis media is scheduled for a myringotomy with tube insertion. The nurse knows that the primary purpose of this procedure is to:
A. Remove the infected tissue
B. Drain fluid from the middle ear
C. Improve hearing by removing ossicles
D. Repair a perforated eardrum
Answer: B. Drain fluid from the middle ear
Rationale: A myringotomy with tube insertion is performed to drain fluid from the middle ear and relieve pressure, often resulting from chronic otitis media. The procedure does not involve removing infected tissue, removing ossicles, or repairing a perforated eardrum. Instead, it helps prevent recurrent infections and improve hearing by allowing proper drainage and aeration of the middle ear.
A patient is scheduled for a total knee replacement. Which of the following preoperative instructions should the nurse provide to the patient?
A. “Avoid taking any medications the morning of surgery.”
B. “You will need to stay in bed for the first 24 hours after surgery.”
C. “Expect to start physical therapy the day after surgery.”
D. “Remove all metal objects, including dental work, before surgery.”
Answer: C. “Expect to start physical therapy the day after surgery.”
Rationale: Physical therapy usually begins the day after a total knee replacement to promote mobility and prevent complications. Patients may be instructed to take certain medications with a sip of water on the morning of surgery. Early ambulation is encouraged, and it is not necessary to remove dental work before surgery.
A patient undergoing treatment for breast cancer asks the nurse about the side effects of tamoxifen. Which of the following side effects should the nurse mention?
A. Joint pain
B. Increased risk of endometrial cancer
C. Hair loss
D. Insomnia
Answer: B. Increased risk of endometrial cancer
Rationale: Tamoxifen, a selective estrogen receptor modulator used in breast cancer treatment, is associated with an increased risk of endometrial cancer. Joint pain and insomnia are not common side effects of tamoxifen, and hair loss is more commonly associated with chemotherapy, not tamoxifen.
A nurse is caring for a patient with peptic ulcer disease (PUD). Which of the following medications should the nurse expect to administer to reduce gastric acid secretion?
A. Sucralfate (Carafate)
B. Metoclopramide (Reglan)
C. Omeprazole (Prilosec)
D. Misoprostol (Cytotec)
Answer: C. Omeprazole (Prilosec)
Rationale: Omeprazole is a proton pump inhibitor (PPI) that reduces gastric acid secretion, which helps in the treatment of peptic ulcer disease (PUD). Sucralfate forms a protective barrier over ulcers but does not reduce acid secretion. Metoclopramide enhances gastric emptying but does not reduce acid secretion. Misoprostol is a prostaglandin analogue that helps prevent NSAID-induced ulcers but does not significantly reduce acid secretion.
A nurse is assessing a patient immediately after surgery. Which finding requires immediate intervention?
A. Serosanguineous drainage on the surgical dressing
B. Temperature of 99.8°F (37.7°C)
C. Respiratory rate of 18 breaths per minute
D. Blood pressure of 90/60 mmHg
Answer: D. Blood pressure of 90/60 mmHg
Rationale:
A blood pressure of 90/60 mmHg indicates hypotension, which could be a sign of hypovolemia or hemorrhage postoperatively and requires immediate intervention to prevent complications. Serosanguineous drainage on the surgical dressing, a slight elevation in temperature, and a normal respiratory rate are within expected parameters postoperatively.
A nurse is educating a patient with newly diagnosed Meniere’s disease. Which of the following instructions should the nurse include in the teaching plan? (Select all that apply)
A. Follow a low-sodium diet.
B. Avoid caffeine and alcohol.
C. Lie down immediately when experiencing vertigo.
D. Increase fluid intake to at least 3 liters per day.
E. Take antihistamines as prescribed.
Answers: A. Follow a low-sodium diet., B. Avoid caffeine and alcohol., C. Lie down immediately when experiencing vertigo., E. Take antihistamines as prescribed.
Rationale: Meniere’s disease management includes dietary modifications such as a low-sodium diet to help reduce fluid retention, avoiding caffeine and alcohol which can worsen symptoms, lying down during vertigo episodes to prevent falls, and taking prescribed medications like antihistamines to reduce symptoms. Increasing fluid intake is not typically recommended as it can exacerbate fluid retention.
A nurse is caring for a patient with a cast on their lower leg. Which of the following signs indicates that the patient may be developing compartment syndrome?
A. Itching under the cast
B. Pain unrelieved by medication
C. Warmth around the cast
D. Increased mobility of the toes
Answer: B. Pain unrelieved by medication
Rationale: Pain unrelieved by medication, particularly pain that is out of proportion to the injury, is a key sign of compartment syndrome. Itching under the cast is common and not indicative of compartment syndrome. Warmth around the cast can be normal due to healing, and increased mobility of the toes is not associated with compartment syndrome.
A nurse is providing education to a patient with HIV about preventing opportunistic infections. Which of the following instructions should the nurse include? (Select all that apply)
A. “Avoid raw or undercooked foods.”
B. “Wash your hands frequently.”
C. “Get regular dental check-ups.”
D. “Use a barrier method during sexual activity.”
E. “Share personal items like razors and toothbrushes.”
Answers: A. “Avoid raw or undercooked foods.”, B. “Wash your hands frequently.”, C. “Get regular dental check-ups.”, D. “Use a barrier method during sexual activity.”
Rationale: Patients with HIV should avoid raw or undercooked foods to reduce the risk of foodborne infections, wash hands frequently to prevent infections, get regular dental check-ups to maintain oral health, and use barrier methods during sexual activity to prevent transmission of infections. Sharing personal items like razors and toothbrushes is not recommended as it can transmit infections.
A nurse is assessing a patient diagnosed with peritonitis. Which of the following findings should the nurse expect? Select all that apply:
A. Constipation
B. Rigidity and guarding of the abdomen
C. Normal bowel sounds
D. Rebound tenderness
E. Bradycardia
Answers: B. Rigidity and guarding of the abdomen, D. Rebound tenderness
Rationale:
• B. Rigidity and guarding of the abdomen: Rigidity and guarding are classic signs of peritonitis due to inflammation and irritation of the peritoneum.
• D. Rebound tenderness: Rebound tenderness occurs when pressure is applied and then released on the abdomen, causing pain. It is a common finding in peritonitis due to the inflamed peritoneum.
• A. Constipation: Constipation is less likely in peritonitis; patients often experience bowel changes such as diarrhea or absent bowel movements due to ileus.
• C. Normal bowel sounds: Peritonitis typically causes decreased or absent bowel sounds due to ileus rather than normal bowel sounds.
• E. Bradycardia: Bradycardia is not typically associated with peritonitis; tachycardia is more common due to the body’s response to infection and inflammation.
A nurse is preparing a patient for surgery. Which interventions should the nurse include in the preoperative checklist? Select all that apply:
A. Verify the patient’s identity and surgical site
B. Administer preoperative antibiotics
C. Ensure the patient has signed the informed consent
D. Complete a thorough skin assessment
E. Remove dentures and prosthetics
F. Check the patient’s blood type
Answers: A. Verify the patient’s identity and surgical site, B. Administer preoperative antibiotics, C. Ensure the patient has signed the informed consent, E. Remove dentures and prosthetics
Rationale:
• A. Verify the patient’s identity and surgical site: Verification is crucial to prevent wrong-patient or wrong-site surgery.
• B. Administer preoperative antibiotics: Prophylactic antibiotics are given before surgery to reduce the risk of surgical site infections.
• C. Ensure the patient has signed the informed consent: Informed consent is a legal and ethical requirement before any surgical procedure.
Completing a thorough skin assessment and checking the patient’s blood type are important aspects of preoperative preparation but are not typically part of the preoperative checklist for all patients.
• E. Remove dentures and prosthetics: Removing dentures and prosthetics prevents airway obstruction and ensures safety during anesthesia.