a client has sustained a hyphema what intervention should the nurse take a client has sustained a hyphema what intervention should the nurse take
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Nursing Elites

NCLEX NCLEX-PN

Nclex Questions Management of Care

1. What intervention should the nurse take for a client who has sustained a hyphema?

Correct answer: Keep the client at bed rest, typically with the head of the bed propped up

Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.

2. Regardless of their practice area, nurses should be concerned with:

Correct answer: transmission of microorganisms.

Rationale: All nurses should be concerned with preventing the transmission of microorganisms to themselves and others. A primary way to achieve this is through asepsis. Nursing practice emphasizes providing a safe environment to shield clients, family, and healthcare providers from infections. Choices A, B, and D are incorrect. While drug-resistant bacteria, critical microorganisms, and overprescription of bacteriostatic drugs are important, nurses' primary focus should be on preventing microorganism transmission to ensure safety and well-being.

3. When evaluating the lab work of a client in hepatic coma, which of the following lab tests is most important?

Correct answer: serum ammonia

Rationale: When a client is in hepatic coma due to liver failure, the liver cannot metabolize amino acids completely, leading to elevated ammonia levels. Increased ammonia can cause brain-tissue irritation, worsening the coma. Therefore, monitoring serum ammonia levels is crucial in assessing the severity of hepatic coma. Choices A, B, and D are less relevant in the context of hepatic coma. Blood urea nitrogen primarily assesses kidney function, serum calcium levels are not directly related to hepatic coma, and serum creatinine is more indicative of kidney function rather than liver function in this scenario.

4. A client, age 28, was recently diagnosed with Hodgkin’s disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP—nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?

Correct answer: Alopecia

Rationale: The correct answer is B: Alopecia. Chemotherapy drugs like vincristine can cause alopecia, which is hair loss. This side effect can significantly impact a patient's body image. While Cushingoid appearance (A) can be a side effect of long-term steroid use, temporary or permanent sterility (C) may affect a patient's future fertility but not necessarily alter body image. Pathologic fractures (D) are not common side effects of Hodgkin's disease or its treatment and do not directly contribute to a sense of altered body image in the same way as alopecia does.

5. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.

Correct answer: A, D

Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client’s pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.

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