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NEW QUESTION 20
The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?

• A. "I will maintain the sterility of the eye medications."
• B. "I will wear sunglasses when going outside."
• C. "I will wash my hands before instilling eye medications."
• D. "I will wear an eye patch for the first 3 postoperative days."

Answer: D

Explanation:
Explanation
(A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye.
(C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.

NEW QUESTION 21
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:

• A. Maintaining seizure precautions
• B. Increasing sensory stimuli
• C. Restricting fluid intake
• D. Applying ankle and wrist restraints

Answer: A

Explanation:
Explanation
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.

NEW QUESTION 22
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

• A. An asthma attack
• B. Pulmonary embolus
• C. Pneumonia
• D. A tension pneumothorax

Answer: A

Explanation:
Section: Questions Set D
Explanation:
(A) A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. (B) Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings:
agitation, nasal flaring, tachypnea, and expiratory wheezing. (C) Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation.
Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus.
(D) A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.

NEW QUESTION 23
A 6-year-old child returned to the surgical floor 20 hours ago after an appendectomy for a gangrenous appendix. His mother tells the nurse that he is becoming more restless and is anxious. Assessment findings indicate that the child has atelectasis. Appropriate nursing actions would include:

• A. Administering analgesics as ordered
• B. Allowing the child to remain in the position of comfort, preferably semi-or high-Fowler position
• C. Remaining with the child and keeping as calm and quiet as possible
• D. Having the child turn, cough, and deep breathe every 1-2 hours

Answer: D

Explanation:
Explanation/Reference:
Explanation:
(A) Allowing the client to remain in the position of comfort will not resolve the atelectasis. This position, if left unchanged, over time may actually increase the atelectasis. (B) Analgesics will not resolve the atelectasis and may contribute to it if proper nursing actions are not taken to help resolve the atelectasis.
(C) Having the client turn, cough, and deep breathe every 1-2 hours will aid in resolving the atelectasis.
Surgery clients are at risk for postoperative respiratory complications because pulmonary function is reduced as a result of anesthesia and surgery. (D) Remaining with the client and keeping him calm and quiet will not affect the client's anxiety, restlessness, or help to resolve the atelectasis. The cause (atelectasis) needs to be treated, not the symptoms (anxiety and restlessness).

NEW QUESTION 24
A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice.
The nurse's response is based on the knowledge that:

• A. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
• B. Heat would help to relax the abdominal muscles and relieve her pain
• C. The symptoms could easily have been caused by constipation, which an enema would relieve
• D. Complaints of stomach ache are common in young children and are generally best ignored

Answer: A

Explanation:
Explanation/Reference:
Explanation:
(A) Constipation does not cause fever or vomiting but may cause anorexia. Risk of perforation outweighs the possible benefits of an enema. (B) Heat will not relieve her symptoms but will increase intestinal motility and increase the risk of perforation. (C) Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation. (D) Complaints accompanied by physical symptoms such as pain, anorexia, and fever should never be ignored.

NEW QUESTION 25
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