SATA NCLEX QUESTIONS AND ANSWERS WITH RATIONALE

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular

implant. Which home care measures will the nurse include in the plan? Select all that apply.

1. To avoid activities that require bending over

2. To contact the surgeon if eye scratchiness occurs

3. To place an eye shield on the surgical eye at bedtime

4. That episodes of sudden severe

pain in the eye is expected

5. To contact the surgeon if a decrease in visual acuity occurs

6. To take acetaminophen (Tylenol) for minor eye discomfort

1,3,5,6

Rationale:

After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is

usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon

because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would 

also

instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in 

visual

acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the 

eye

from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme

dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse 

immediately

notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

1. Administering oxygen

2. Inserting a Foley catheter

3. Administering furosemide (Lasix)

4. Administering morphine sulfate intravenously

5. Transporting the client to the coronary care unit

6. Placing the client in a low Fowler's side-lying position

1,2,3,4

Rationale:

Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary

edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the

accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to

ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley

catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces

venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client 

to

the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's

response to treatment is successful