Nokea
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- A. I have constant blurred vision.
- B. I can't see on my left side.
- C. I have to turn my head to see my room.
- D. I have specks floating in my eyes.
Correct Answer: C
Rationale: I have to turn my head to see my room. Intraocular pressure becomes elevated, producing a progressive loss of the peripheral visual field in the affected eye.
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When admitting a client who has acute glomerulonephritis, the nurse expects that the client will report which information?
- A. Recent bladder infection
- B. History of previous kidney infections
- C. Pharyngitis three weeks ago
- D. Multiple sexual partners
Correct Answer: C
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis. Bladder/kidney infections or sexual partners are less directly related.
The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor.
Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
- A. The client lets her hand dangle before sticking her finger with the lancet.
- B. The client sticks her finger on the side of the distal phalanx.
- C. The client touches the strip with a large drop of blood hanging from her fingertip.
- D. The client milks her finger after sticking it.
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) helps to facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct-forces interstitial fluid to mix with capillary blood and dilutes the blood
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Continue to monitor the client to see if the bubbling increases
- D. Instruct the client to try to avoid coughing
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to
- A. suction the patient frequently.
- B. provide an air mattress.
- C. turn the patient every two hours.
- D. give the patient frequent baths.
Correct Answer: C
Rationale: Turning every two hours prevents pressure ulcers in immobile cancer patients, a priority for skin integrity. Options A, B, and D are less critical unless specifically indicated.
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following instructions should the nurse include?
- A. Take the medication daily to prevent migraines.
- B. Report any chest pain.
- C. Stop the medication if headaches decrease.
- D. Avoid regular neurological exams.
Correct Answer: B
Rationale: Chest pain may indicate vasoconstriction, a serious sumatriptan side effect. Options A, C, and D are incorrect.