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A nurse is collecting data on a 58-year-old client with blurred vision and reduced visual fields. The nurse finds which manifestation most concerning?
- A. Difficulty adjusting to dimmed lights
- B. Extreme eye pain
- C. Gradual loss of peripheral vision
- D. Opaque appearance of lens
Correct Answer: B
Rationale: Extreme eye pain (B) suggests acute conditions like glaucoma, requiring urgent attention. Difficulty in dim light (A), peripheral vision loss (C), and cataracts (D) are less acute.
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An elderly client is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe. Which prescription should the nurse question?
- A. Albuterol 2.5 mg by nebulizer
- B. IV methylprednisolone 125 mg now and every 6 hours
- C. IV morphine 2 mg now, may repeat every 2 hours
- D. Oxygen at 2 L/min by nasal cannula
Correct Answer: C
Rationale: Morphine (C) can depress respiration in COPD, worsening hypoxia, and should be questioned. Albuterol (A) relieves bronchospasm, methylprednisolone (B) reduces inflammation, and oxygen (D) addresses hypoxia, all appropriate for COPD exacerbation.
The licensed practical nurse (LPN) is collecting data on several clients in the antepartum unit. Which of the following clients should the LPN report to the registered nurse for further assessment?
- A. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL (6.6 mmol/L)
- B. 25 weeks gestation, hemoglobin is 9 g/dL (90 g/L)
- C. 30 weeks gestation, nonstress test is reactive
- D. 36 weeks gestation, WBC count is 13,000/mm^3 (13 x 10^9/L)
Correct Answer: B
Rationale: Hemoglobin of 9 g/dL (B) indicates anemia, requiring further assessment. Normal glucose (A), reactive nonstress test (C), and slightly elevated WBC (D) are less urgent.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
The nurse is caring for a newly admitted man who has kidney stones. The man asks if he can get up and take a walk. How should the nurse respond?
- A. It is better for you to remain in bed until the stones pass.'
- B. Stay in bed until I check with your physician.'
- C. Walking is good for you. Let me help you up.'
- D. It is safe for you to ambulate once a day.'
Correct Answer: C
Rationale: Walking may facilitate kidney stone passage and is generally safe unless contraindicated, with assistance ensuring safety.
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
- A. Right ventricle, left ventricle, right atrium, left atrium
- B. Left ventricle, right ventricle, left atrium, right atrium
- C. Right atrium, right ventricle, left atrium, left ventricle
- D. Right atrium, left atrium, right ventricle, left ventricle
Correct Answer: C
Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.