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 C

Explanation

Choice A Reason: Cold skin is not a common finding in hyperthyroidism, but it may indicate hypothyroidism or other conditions such as hypothermia or shock.

Choice B Reason: Weight gain is not a common finding in hyperthyroidism, but it may indicate hypothyroidism or other conditions such as Cushing's syndrome or edema.

Choice C Reason: Tachycardia is a common finding in hyperthyroidism, as the increased thyroid hormone level causes the heart rate and cardiac output to increase.

Choice D Reason: Anorexia is not a common finding in hyperthyroidism, but it may indicate other conditions such as depression, infection, or cancer.

A. Fatigue B. Anorexia C. Bleeding D. Fever

Correct Answer is C

Explanation

Choice A Reason: Fatigue is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as anemia, infection, or depression.

Choice B Reason: Anorexia is not the priority finding for a client who has a low platelet count, as it may indicate other conditions such as nausea, pain, or anxiety.

Choice C Reason: Bleeding is the priority finding for a client who has a low platelet count, as it indicates that the client is at risk of hemorrhage and shock due to impaired blood clotting.

Choice D Reason: Fever is not the priority finding for a client who has a low platelet count, but it may indicate an infection that requires prompt treatment.

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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

The nurse is completing a health assessment of a client suspected of hyperthyroidism. Which of the following clinical manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving chemotherapy and has a platelet count of 20,000 mm3. Which of the following findings should the nurse identify as the priority?

Correct Answer is C

Explanation

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