which instruction should the nurse include in the discharge teaching plan for a client who has had a cataract extraction today
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HESI Test Bank Medical Surgical Nursing

1. Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?

Correct answer: C

Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.

2. A community hit by a hurricane has suffered mass destruction and flooding. Several facilities are not functioning, and the area is contaminated with human excretions. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?

Correct answer: B

Rationale: Providing fluid and electrolyte replacement is the highest priority to prevent dehydration and shock in clients with cholera. Administering prophylactic antibiotics may be necessary but is not the highest priority. Isolating infectious diarrhea victims is important for preventing the spread of infection, but addressing fluid and electrolyte imbalances takes precedence. Administering a cholera vaccine is preventive and not the immediate priority in treating clients already diagnosed with cholera.

3. What pathophysiologic process is producing the symptoms of gout in a client with sudden onset of big toe joint pain and swelling?

Correct answer: A

Rationale: The correct answer is A. Gout is characterized by the deposition of uric acid crystals in the synovial fluid of joints, which triggers inflammation and pain. This process is known as crystal-induced arthritis. Choice B is incorrect as gout does not involve degeneration of joint cartilage. Choice C is incorrect as gout is not caused by an infection of the joint space. Choice D is incorrect as gout does not result from increased synovial fluid but rather from the deposition of uric acid crystals.

4. What is a priority action for the nurse when caring for a client with suspected meningitis?

Correct answer: B

Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.

5. How is gastroesophageal reflux (GER) typically treated in infants?

Correct answer: B

Rationale: Gastroesophageal reflux (GER) in infants is typically treated by thickening the formula or breast milk with cereal. This helps reduce reflux episodes by making the feedings heavier and less likely to come back up. Placing the infant NPO (nothing by mouth) is not the typical treatment for GER as infants need proper nutrition for growth. Placing the infant to sleep on the side is not recommended due to the risk of SIDS; infants should be placed on their back to sleep. Switching the infant to cow's milk is also not a treatment for GER, as cow's milk can be harder to digest and may exacerbate symptoms.

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