Nokea
During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?
- A. Position the client 6.1 m (20 ft) away from the Snellen chart
- B. Instruct the client to follow a finger through the six cardinal positions of gaze
- C. Ask the client to cover their right eye during assessment of the left eye
- D. Hold a finger 46 cm (18 inches) away from the client's eye
Correct Answer: B
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.
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While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?
- A. Albumin level of 3 g/dL
- B. Hemoglobin level of 12 g/dL
- C. WBC count of 6,000/mm³
- D. Blood glucose level of 100 mg/dL
Correct Answer: A
Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.
A client with rheumatoid arthritis is prescribed methotrexate. What information should the LPN include when teaching the client about this medication?
- A. Avoid exposure to sunlight.
- B. Take the medication with food.
- C. Increase fluid intake while on this medication.
- D. Report any signs of infection to the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: 'Report any signs of infection to the healthcare provider immediately.' Methotrexate is an immunosuppressant medication commonly used to treat rheumatoid arthritis. It can lower the immune system's ability to fight infections, making it crucial for clients to promptly report any signs of infection to prevent serious complications. Choices A, B, and C are incorrect because avoiding sunlight, taking the medication with food, and increasing fluid intake are not specific to methotrexate therapy and are not primary concerns associated with this medication.
A healthcare provider is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the provider identify as an adverse effect of opioids?
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. Opioids can cause orthostatic hypotension, leading to a sudden drop in blood pressure when changing positions. This effect is due to the vasodilatory properties of opioids, which can result in decreased blood flow to the brain upon standing up. Choices A, B, and C are incorrect. Urinary incontinence and diarrhea are not typical adverse effects of opioids. Bradypnea, or slow breathing, is a potential side effect of opioid overdose or respiratory depression, but it is not a common adverse effect following normal opioid administration.
A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?
- A. Schedule a support session for the client.
- B. Explain the techniques of esophageal speech.
- C. Review the use of artificial larynx with the client.
- D. Determine the client's reading ability.
Correct Answer: B
Rationale: The priority intervention for a client scheduled for a total laryngectomy is to explain the techniques of esophageal speech. This is crucial for the client's post-surgery communication. Option A, scheduling a support session, is important but not the priority as ensuring the client can communicate effectively comes first. Option C, reviewing the use of artificial larynx, is relevant but not the priority compared to teaching esophageal speech. Option D, determining the client's reading ability, is not as critical as ensuring the client learns a primary method of communication following the laryngectomy.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since timed-release capsules are not available at the time of discharge, which dosing schedule should the LPN advise the client to follow?
- A. 9 a.m., 1 p.m., and 5 p.m.
- B. 8 a.m., 4 p.m., and midnight.
- C. Before breakfast, before lunch, and before dinner.
- D. With breakfast, with lunch, and with dinner.
Correct Answer: B
Rationale: The correct dosing schedule for the client to follow is to take the medication at 8 a.m., 4 p.m., and midnight. This timing spaces the doses evenly over the waking hours, ensuring consistent therapeutic levels of the medication. Choice A (9 a.m., 1 p.m., and 5 p.m.) does not evenly distribute the doses throughout the day. Choices C (Before breakfast, before lunch, and before dinner) and D (With breakfast, with lunch, and with dinner) do not provide the required frequency of dosing needed for optimal therapeutic effect.