A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

"l stopped taking aspirin last week."

"l did not put my contact lenses in this morning."

"l took my blood pressure meds with a sip of water."

"l had a cough and runny nose a couple days ago."

Answer and Explanation

The Correct Answer is D

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

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Correct Answer is D

Explanation

A. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow breathing rate) may indicate a slowing down of bodily functions but are not typical manifestations of postoperative shock. In postoperative shock, the body's compensatory mechanisms often lead to tachycardia (rapid heart rate) and tachypnea (rapid breathing rate) as the body tries to maintain perfusion.

B. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically associated with postoperative shock. In shock, metabolic acidosis is more common due to tissue hypoperfusion, and extremities may become cool due to peripheral vasoconstriction as the body attempts to shunt blood to vital organs.

C. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (lack of urine output) are not indicative of postoperative shock. In shock, blood pressure typically decreases (hypotension), and oliguria or anuria may occur due to decreased renal perfusion.

D. The client has hypotension and is confused: This is the correct answer. Hypotension (low blood pressure) is a hallmark sign of shock, indicating inadequate tissue perfusion. Confusion may occur due to cerebral hypoperfusion and inadequate oxygen delivery to the brain. Confusion is a late sign of shock and indicates severe compromise of organ perfusion.

A. "You can have 2 to 3 cups of coffee throughout the day." B. "You should practice deep breathing exercises:' C. "You can use at least 2,300 mg of sodium daily." D. "You should avoid exercising."

Correct Answer is B

Explanation

A. "You can have 2 to 3 cups of coffee throughout the day": Caffeine consumption can exacerbate tinnitus symptoms in some individuals. Therefore, advising the client to limit caffeine intake, rather than specifying a quantity, would be more appropriate.

B. "You should practice deep breathing exercises": Deep breathing exercises and relaxation techniques can help reduce stress and anxiety, which may contribute to tinnitus symptoms. Stress management strategies can be beneficial in managing tinnitus-related distress.

C. "You can use at least 2,300 mg of sodium daily": High sodium intake may exacerbate tinnitus symptoms in some individuals. Advising the client to limit sodium intake would be more appropriate to potentially alleviate symptoms.

D. "You should avoid exercising": Regular exercise is generally beneficial for overall health and well-being, including stress reduction, which can help manage tinnitus symptoms. Therefore, advising the client to avoid exercising is not appropriate.

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A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A nurse is instructing a client who is experiencing episodes of tinnitus on lifestyle modifications to make. Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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