The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular
implant. Which home care measures will the nurse include in the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness...
The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with
intraocular
implant. Which home care measures will the nurse include in the plan? Select all that apply.
1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe
pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort - ANS 1,3,5,6
Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye
and is
usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the
surgeon
because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse
would also
instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease
in visual
acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect
the eye
from injury during sleep and to avoid activities that increase intraocular pressure such as
bending over.
A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops
extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse
immediately
notifies the registered nurse and expects which interventions to be prescribed? Select all that
apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
,6. Placing the client in a low Fowler's side-lying position - ANS 1,2,3,4
Rationale:
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary
edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs
because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's
position to
ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid.
A Foley
catheter is inserted to accurately measure output. Intravenously administered morphine sulfate
reduces
venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the
client to
the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the
client's
response to treatment is successful
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly
becomes
cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the
nurse should
perform. Select all that apply.
1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask. - ANS 2,4,5,6
Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic
episode.
Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur
among
infants whose heart defect includes the obstruction of pulmonary blood flow and communication
between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest
position
immediately. The registered nurse is notified, who will then contact the health care provider. The
knee-
chest position improves systemic arterial oxygen saturation by decreasing venous return so that
smaller
, amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this
position
and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease.
Additional
interventions include administering 100% oxygen by face mask, morphine sulfate, and
intravenous fluids,
as prescribed.
A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone
(SIADH) as a complication of the cancer. The nurse anticipates that which of the following may
be
prescribed? Select all that apply.
1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone (ADH) - ANS 1,2,4,6
Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are
reabsorbed
by the kidney and put into the systemic circulation. The increased water causes hyponatremia
(decreased
serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the
condition
and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a
medication
with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely,
because
hypernatremia can suddenly develop as a result of treatment. The immediate institution of
appropriate
cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that
ADH
synthesis and release processes return to normal.
A nurse prepares a list of home care instructions for the parents of a child who has a plaster
cast applied
to the left forearm. Choose the instructions that would be included on the list. Select all that
apply.
1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller DocLaura. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.89. You're not tied to anything after your purchase.
