The nurse places eye drops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient
Which of the following patient statements indicate that further instruction is needed? (Select all that apply.)
a. "I can watch television without moving my eye too much."
b. "I can listen to music or an audiotaped book but should not read or watch TV."
c. "I should try to open my eyelid under the patch hourly while awake."
d. "I should exercise my patched eye four times daily."
e. "I should apply pressure to the tear duct of the eye every 5 minutes."
f. "When I change the patch, it should be taped securely enough to help the eyelid stay closed."
ANS: A, C, D, E
A, C, D, and E should not be done, so the patient would need further instruction for understanding. B and F are correct and would indicate understanding.
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A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
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A patient newly diagnosed with cancer is admitted to the hospital, and the provider orders oxycodone [OxyContin] every 4 to 6 hours PRN pain
The patient requests pain medication whenever he reports pain as a 7 or 8 on a scale of 1 to 10 (10 being the worst pain), but he tells the nurse the medication is not working well. The nurse will contact the provider to discuss: a. a fixed dosing schedule for the oxyco-done. b. intramuscular meperidine [Demerol]. c. intravenous morphine sulfate. d. transdermal fentanyl.
A patient arrives in the emergency department after developing a rash, runny nose, and sneezing after eating strawberries. What action will the nurse expect to take first?
a. Administer diphenhydramine. b. Administer epinephrine. c. Assess for urinary retention. d. Assess heart rate, respiratory rate, and lung sounds.
A client is prescribed an antihistamine for an allergic reaction. The client asks, "Why am I getting this? What is a histamine anyway?" How can the nurse most accurately describe the action of histamine in the body?
1. "Histamine causes your blood vessels to dilate and leak. That is why you are swollen and itchy." 2. "Histamine stimulates production of the clotting parts of your blood. That is why you are blotchy." 3. "Histamine stimulates production of white blood cells to fight off infection. That is why you feel flushed." 4. "Histamine stimulates production of the red cells of your blood. That is why you are red."