A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye unrelieved by pain medications. Which of the following actions should the nurse take first?

Tell the client that this is to be expected after surgery.

Place the client in a supine position.

Document the findings.

Notify the surgeon.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Telling the client that this is to be expected after surgery is not the first action that the nurse should take, as it may indicate a complication such as increased intraocular pressure, hemorrhage, or infection.

Choice B Reason: Placing the client in a supine position is not the first action that the nurse should take, as it may worsen the pain and increase intraocular pressure.

Choice C Reason: Documenting the findings is not the first action that the nurse should take, as it may delay the intervention and outcome.

Choice D Reason: Notifying the surgeon is the first action that the nurse should take, as it indicates that the client needs immediate evaluation and treatment to prevent vision loss or permanent damage to the eye.

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Correct Answer is A

Explanation

Choice A Reason: Murphy sign is a finding that indicates cholecystitis, which is inflammation of the gallbladder. It is elicited by palpating the right upper quadrant of the abdomen and asking the client to take a deep breath. The client will experience pain and stop breathing in if cholecystitis is present.

Choice B Reason: McBurney sign is a finding that indicates appendicitis, which is inflammation of the appendix. It is elicited by palpating the right lower quadrant of the abdomen at a point one-third of the distance from the anterior superior iliac spine to the umbilicus. The client will experience pain and tenderness if appendicitis is present.

Choice C Reason: Cullen's sign is a finding that indicates intra-abdominal bleeding, which can be caused by various conditions such as ruptured ectopic pregnancy, pancreatitis, or trauma. It is characterized by bruising around the umbilicus due to blood accumulation under the skin.

Choice D Reason: Homan sign is a finding that indicates deep vein thrombosis (DVT), which is a blood clot in a deep vein, usually in the leg. It is elicited by dorsiflexing the foot and squeezing the calf muscle. The client will experience pain and resistance if DVT is present.

A. Checks blood sugar then eats breakfast prior to injecting insulin. B. Rotates sites from arms, legs, and abdomen. C. Ensures the use of insulin syringe with units. D. Activates the safety lock on the syringe before disposing in a sharps container.

Correct Answer is A

Explanation

Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.

Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.

Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.

Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.

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A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye unrelieved by pain medications. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with data collection of a client with suspected cholecystitis. Which finding does the nurse expect to note if cholecystitis is present?

Correct Answer is A

Explanation

When evaluating a client how to administer insulin, which action indicates that additional teaching is necessary?

Correct Answer is A

Explanation

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