Nokea
If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct Answer: A
Rationale: The numerator, which is always 20, is the distance in feet between the chart and the client. The denominator, which ranges from 10 to 200, indicates the distance at which a normal eye can read the chart.
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The nurse is caring for a client with a nasogastric tube.
- A. What is the most appropriate action for the nurse to take if the nasogastric tube appears occluded?
- B. Replace the nasogastric tube.
- C. Irrigate the tube with warm saline.
- D. Advance the tube 3-5 cm.
- E. Reposition the client to the left side.
Correct Answer: B
Rationale: Irrigating the nasogastric tube with warm saline is the first step to clear an occlusion, restoring function. Replacing the tube is invasive, advancing it risks misplacement, and repositioning does not address the occlusion directly.
The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.
Which of the following observations is MOST important for the nurse to report to the next shift?
- A. The client indicates the need to use the bathroom.
- B. Blood pressure has decreased from 140/80 to 90/60.
- C. Respiratory rate has increased from 16 to 24.
- D. The client indicates that the chest pain has subsided.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome
A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding.
- A. Which statement by a woman at 38-weeks gestation with vaginal bleeding suggests placenta previa?
- B. I feel fine, but the bleeding scares me.'
- C. I’ve been more nauseated during the past few weeks.'
- D. The bleeding started after I carried four bags of groceries.'
- E. I’ve been having severe abdominal cramps.'
Correct Answer: A
Rationale: Placenta previa is characterized by painless vaginal bleeding, as the placenta covers the cervical os. The statement ‘I feel fine, but the bleeding scares me’ indicates bleeding without pain, consistent with placenta previa. Nausea, activity-related bleeding, or cramps suggest other causes like abruptio placentae.
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement
- B. Note the time from beginning to end
- C. Identify the pattern of breathing
- D. Determine if loss of bowel or bladder control occurs
Correct Answer: A
Rationale: Observe the sequence or types of movement. Noting movement types is critical for diagnosis and guiding treatment.
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.