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Questions 227

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Extract:

The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:


Question 1 of 5

The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:

Correct Answer: C

Rationale: Atropine increases intraocular pressure, worsening glaucoma, indicating correct understanding.

Extract:


Question 2 of 5

A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?

Correct Answer: A

Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding.
Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.

Question 3 of 5

A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?

Correct Answer: B

Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity

Extract:

A client has been on antibiotics for 72 hours for cystitis.


Question 4 of 5

Which report from the client requires priority attention by the nurse?

Correct Answer: C

Rationale: Rashes and breathing problems are signs of a delayed allergic reaction to antibiotics, requiring urgent attention.

Extract:


Question 5 of 5

The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:

Correct Answer: B,D,C,A

Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.

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