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A nurse in an ophthalmology clinic assesses a client suspected of having cataracts. What is an expected symptom?
- A. Eye pain
- B. Sudden vision loss
- C. Decreased ability to perceive colors
- D. Excessive tearing
Correct Answer: C
Rationale: The correct answer is C: Decreased ability to perceive colors. Cataracts cause clouding of the eye's lens, leading to a decrease in the perception of colors. Eye pain (A) is not a typical symptom of cataracts. Sudden vision loss (B) is more commonly associated with conditions like retinal detachment. Excessive tearing (D) is not a prominent symptom of cataracts. Make sure to assess for other symptoms like blurred vision, sensitivity to light, and difficulty seeing at night.
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A nurse is teaching about adverse effects of anastrozole with a client who has advanced breast cancer and is postmenopausal. Which of the following adverse effects should the nurse recommend the client report to the provider?
- A. Fatigue
- B. Hot flashes
- C. Musculoskeletal pain
- D. Nausea
Correct Answer: C
Rationale: The correct answer is C: Musculoskeletal pain. Anastrozole, an aromatase inhibitor used in breast cancer treatment, can cause musculoskeletal pain as a common adverse effect. This is important to report to the provider as it may indicate musculoskeletal issues such as osteoporosis or arthritis. Fatigue (A) and hot flashes (B) are common side effects of anastrozole but not typically indicative of serious issues requiring immediate attention. Nausea (D) is also a common side effect but is usually manageable and not a significant concern unless severe. It is crucial for the nurse to prioritize musculoskeletal pain as a potential indicator of more serious complications.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
- A. Administering a nebulized beta-adrenergic
- B. Providing supplemental oxygen
- C. Administering an intravenous corticosteroid
- D. Encouraging the client to use their inhaler
Correct Answer: A
Rationale: The correct answer is A: Administering a nebulized beta-adrenergic. This is the highest priority because it helps to rapidly dilate the bronchioles, improving airflow and oxygenation in the client. This immediate action is crucial in managing an acute asthma exacerbation and can prevent respiratory distress. Providing supplemental oxygen (B) is important but not the highest priority. Administering an intravenous corticosteroid (C) is beneficial for reducing inflammation but takes longer to take effect compared to a beta-adrenergic. Encouraging the client to use their inhaler (D) is helpful, but in an acute exacerbation, a nebulized beta-adrenergic is more effective for immediate relief.
A nurse assesses a client 2 hours after TURP. What indicates a complication?
- A. Clear urine output
- B. Burgundy-colored urine output
- C. Mild pain at the incision site
- D. Temperature of 98.6°F
Correct Answer: B
Rationale: The correct answer is B: Burgundy-colored urine output. This indicates a complication post-TURP due to potential bleeding. Clear urine output (A) is normal. Mild pain at the incision site (C) is expected. Temperature of 98.6°F (D) is within normal range.
A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include?
- A. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
- B. Avoid reading for 1 week.
- C. Limit eye movements for 1 week.
- D. Do not bend forward at the waist for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. This is important to prevent increased intraocular pressure that could lead to complications post cataract surgery. Lifting heavy objects can strain the eye and potentially disrupt the healing process.
B: Avoid reading for 1 week is incorrect as reading does not significantly impact intraocular pressure or the healing process post cataract surgery.
C: Limit eye movements for 1 week is incorrect as normal eye movements do not typically pose a risk to the surgical site after cataract extraction.
D: Do not bend forward at the waist for 1 week is incorrect as bending at the waist does not directly affect intraocular pressure or the healing of the eye after cataract surgery.
A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan?
- A. Avoid foods high in fat.
- B. Avoid foods high in carbohydrates.
- C. Eat a high-protein, low-fat diet.
- D. Increase intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A: Avoid foods high in fat. Biliary colic is caused by gallstones, and high-fat foods can trigger gallbladder contractions leading to pain. Therefore, advising the client to avoid foods high in fat can help prevent biliary colic episodes. Choice B is incorrect as carbohydrates do not directly affect biliary colic. Choice C is incorrect because while a high-protein, low-fat diet may be beneficial for some conditions, it is not specifically recommended for biliary colic. Choice D is incorrect as increasing intake of high-fat foods can worsen symptoms.