Nokea
An adult client who was recently diagnosed with glaucoma tells the nurse, 'It feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?
- A. Wear prescription glasses.
- B. Eat a diet high in carotene.
- C. Maintain prescribed eye drop regimen.
- D. Avoid frequent eye pressure measurements.
Correct Answer: C
Rationale: Adhering to eye drops controls intraocular pressure, critical for preventing vision loss in glaucoma.
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A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. The client reports that symptoms seem worse when outdoors and when exercising.
Correct Answer: A,B
Rationale: The ineffective use of the rescue inhaler indicates a severe asthma attack requiring intervention, and worsening symptoms with exercise suggest environmental triggers needing management.
A client reports to the clinic nurse of recently experiencing symptoms of frequent urination, hunger, and great thirst. What finding(s) would the nurse consider as most significant to report to the healthcare provider? Select all that apply.
- A. Total cholesterol 180 mg/dL (4.7 mmol/L).
- B. Hematocrit 45% (0.45 volume fraction).
- C. Random plasma glucose level 200 mg/dL (11.1 mmol/L).
- D. Hemoglobin A1C 7%.
- E. Serum potassium of 4.2 mEq/L (4.2 mmol/L).
Correct Answer: C,D
Rationale: Elevated glucose and HbA1C indicate diabetes, correlating with the client's symptoms and requiring urgent management.
The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?
- A. Keep the room at a comfortable temperature.
- B. Maintain the client in a semi-Fowler's position.
- C. Ensure oral suction is available.
- D. Provide frequent mouth care.
Correct Answer: C
Rationale: Oral suction prevents aspiration of secretions during seizures, ensuring airway patency and safety.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Get an influenza vaccine every year as soon as available.
- B. Using salt, herbs, and spices will Improve the flavor of foods.
- C. Restrict alcoholic beverages to no more than 1-2 per week.
- D. Eat a protein snack 30 minutes before any exercise workout.
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.