Question

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Answer 1

Correct Answers:

Provide an eye shield to be worn while sleeping

Rationale :

🟩 Postoperative protection of the eye is essential to prevent trauma during sleep.

🟩 The eye shield ensures that accidental rubbing or pressure is avoided, which could displace the lens implant or damage the surgical site.

🟩 Eye drops and teaching can be addressed later, but immediate physical protection is the priority in the early recovery phase.

🟩 Coughing and deep breathing are important in many surgeries but are contraindicated post-eye surgery due to pressure risk.

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Answer 2

Correct Answers:

A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).

Rationale :

🟦 Elevated BUN in pancreatitis may reflect hypovolemia and impaired renal perfusion.

🟦 A decrease in BUN indicates that the increased IV fluid rate has successfully restored perfusion and supported kidney function.

🟦 BUN reduction is a key therapeutic goal in fluid resuscitation for pancreatitis, especially when there are signs of third-spacing.

🟦 Other lab changes like blood glucose or HCT are influenced by multiple factors and are less direct indicators of fluid volume restoration.

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Answer 3

Correct Answers:

Neutrophil count.

Rationale :

🟥 Neutrophils are the first line of defense against infection and a key indicator of wound infection or systemic inflammation.

🟥 Wound enlargement may signal underlying infection, requiring lab correlation to confirm an inflammatory or infectious process.

🟥 Neutrophilia (elevated neutrophils) supports the likelihood of bacterial infection.

🟥 CRP is non-specific, and platelet/electrolyte levels do not directly relate to wound status.

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Answer 4

Correct Answers:

Weigh yourself daily at the same time and report excessive weight loss.

Rationale :

🟨 Daily weight is the most accurate indicator of fluid status when on diuretics.

🟨 Sudden weight changes may indicate dehydration or fluid retention, requiring dosage adjustment.

🟨 Clients should weigh themselves under the same conditions each day for consistency.

🟨 Other options (limiting fluid or stopping medication) may lead to complications or non-compliance.

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Answer 5

Correct Answers:

Fever and dysuria.

Rationale :

🟪 Fever signals systemic infection, while dysuria is a classic sign of local urinary tract infection.

🟪 These symptoms together indicate an active infectious process, raising the client’s risk for sepsis and falls.

🟪 Recognizing early signs supports prompt intervention and prevention of complications.

🟪 Azotemia, nocturia, or proteinuria are more chronic indicators, not acute symptoms.

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Answer 6

Correct Answers:

333

Rationale :

🔶 Amount of drug :1 gram = 1,000 mg 🔶Total volume after reconstitution: 3 mL 📌 Concentration(mg/mL)= Total mg ÷ Total volume (mL) 🔶 Concentration= 1000 (mg) ÷ 3 (mL)= 333.33mg/mL ✍Round to the nearest whole number = 333 mg/ mL

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Answer 7

Correct Answers:

Hypoventilation.

Rationale :

🟧 Hypoventilation can lead to respiratory acidosis and carbon dioxide retention, a potentially life-threatening complication of hypothyroidism.

🟧 It reflects severe metabolic slowing and may indicate myxedema coma, an endocrine emergency.

🟧 Other symptoms like weight gain or lethargy are typical but not immediately life-threatening.

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Answer 8

Correct Answers:

Remain upright following meals

Rationale :

⬜ Upright posture reduces reflux by using gravity to prevent gastric contents from entering the esophagus.

⬜ This is the most immediate and impactful behavioral intervention for GERD control.

⬜ Diet and clothing changes help, but positioning has the most direct physiological impact post-meals.

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Answer 9

Correct Answers:

Complete a focused assessment of the abdomen.

Rationale :

🟫 Bleeding post-polypectomy may cause perforation or internal hemorrhage.

🟫 Abdominal assessment evaluates for signs of peritonitis, distention, rigidity, or pain, indicating complications.

🟫 Peripheral pulses and intake/output are important later, but the abdomen must be assessed first.

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Answer 10

Correct Answers:

Stone fragments are collected when straining the client's urine.

Rationale :

🟪 Lithotripsy breaks stones into small fragments that must be passed in urine to confirm success.

🟪 Straining urine for stone pieces confirms the physical breakdown and elimination of stones.

🟪 Absence of symptoms or normal labs does not confirm procedural effectiveness.

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RN-Hesi Medical Surgical Exam 58

No.

1 :
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 :
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 :
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 :
The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 :
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 :
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize

9 :
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 :
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

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RN-Hesi Medical Surgical Exam 58

No.

1 : An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 : While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 : The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 : The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 : The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 : The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize

9 : An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 : While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

1 :
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 :
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 :
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 :
The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 :
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 :
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize

9 :
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 :
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?