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A patient with glaucoma who has been using timolol drops for several days tells the nurse that the eye drops cause eye burning and visual blurring. Which of the following is the best response by the nurse?
- A. These are normal adverse effects of the drug, which should become less bothersome over time.
- B. Discontinue the eye drops and report these symptoms to your healthcare provider immediately.
- C. Apply the drops in the evening to minimize the impact of visual blurring.
- D. Use artificial tears to reduce the burning sensation caused by the drops.
Correct Answer: A
Rationale: Burning and visual blurring are common side effects of timolol, a beta-blocker used for glaucoma, and typically diminish as the patient adjusts to the medication. Discontinuing the drops without medical advice is not recommended, as it may worsen glaucoma. Evening application or artificial tears may not address the underlying issue effectively.
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The nurse is admitting a patient with a head injury after a motor vehicle accident who has shortness of breath and severe eye pain. Which of the following actions should the nurse take first?
- A. Elevate the head to 45 degrees.
- B. Administer the ordered analgesic.
- C. Check the patient's oxygen saturation.
- D. Examine the eye for evidence of trauma.
Correct Answer: C
Rationale: The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions also are appropriate but are not the first action the nurse will take.
The nurse is caring for a patient who had a stapedotomy yesterday. Which of the following findings is most important for the nurse to communicate to the health care provider?
- A. The patient complains of 'congestion' in the ear.
- B. The patient's oral temperature is 38°C (100.4°F).
- C. The patient reports mild dizziness when standing.
- D. The patient has slight redness at the surgical site.
Correct Answer: B
Rationale: An oral temperature of 38°C (100.4°F) after a stapedotomy may indicate a postoperative infection, which requires prompt reporting to the healthcare provider. Congestion, mild dizziness, and slight redness are less urgent, as they may be expected postoperative symptoms unless severe or persistent.
Which of the following actions should the nurse take when communicating with a patient who has a moderate hearing loss?
- A. Overenunciate words.
- B. Speak normally but more slowly.
- C. Increase the volume when speaking.
- D. Use more facial expressions when talking.
Correct Answer: B
Rationale: Patient understanding of the nurse's speech will be enhanced by speaking at a normal tone, but more slowly. Increasing the volume, overenunciating, and exaggerating facial expressions will not improve the patient's ability to comprehend the nurse.
The nurse is caring for a patient with an acute attack of Méni?¨re's disease. Which of the following actions carried out by a family member that is visiting the patient should the nurse intervene?
- A. Raises the side rails on the bed
- B. Turns on the patient's television
- C. Turns the patient to the right side
- D. Places an emesis basin at the bedside
Correct Answer: B
Rationale: Watching television may exacerbate the symptoms of an acute attack of Méni?¨re's disease. The other actions are appropriate.
The nurse is assessing a patient in the outpatient eye clinic who has myopia and presbyopia. Which of the following assessments should the nurse implement to evaluate the effectiveness of the prescribed bifocals?
- A. Strength of the eye muscles
- B. Both near and distant vision
- C. Cloudiness in the eye lenses
- D. Intraocular pressure changes
Correct Answer: B
Rationale: The lenses are prescribed to correct the patient's near and distant vision. The nurse also may assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but these data will not evaluate whether the patient's bifocals are effective.