(66 Q &A) ALL ARE CORRECT
(Detail Solutions and Resource for the test)
2 of 55
What instruction should the nurse include in the discharge teaching plan of a client who had a
cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops
3 of 55
A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is
short of breath, febrile, and coughing green colored sputum. Which intervention should the
nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
4 0f 55
An elder male client tells the nurse that he is loosing sleep because he has to get up several
times at night to go to the bathroom that he has trouble starting his urinary stream and that he
does not feel like his bladder is ever completely empty. Which intervention should the nurse
implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
ANS: C
5 of 55
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection
(UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum
laboratory value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
6 of 55
A client with sickle cell anemia develops a fever during the last hour of administration of a
unit of packed red blood cell. When notifying the healthcare provider what information
should the nurse provide first using the SBAR communication process?
, a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
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