Nokea
The nurse is administering eyedrops to a client with glaucoma. Which of the following is a correct technique for instilling the eyedrops? The eyedrops are placed:
- A. In the lower conjunctival sac.
- B. Near the opening of the lacrimal ducts.
- C. On the cornea.
- D. On the scleral surface.
Correct Answer: A
Rationale: Placing eyedrops in the lower conjunctival sac ensures proper absorption and minimizes irritation or injury to the cornea or sclera.
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A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an I.V. infusion of dextrose 5% in half-normal saline solution at 120 mL/hour. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions?
- A. Ketosis.
- B. Hyperglycemia.
- C. Metabolic syndrome.
- D. Lactic acidosis.
Correct Answer: B
Rationale: Dextrose 5% infusion can lead to hyperglycemia, especially in a client with acute pancreatitis, requiring monitoring.
The nurse is teaching a client with a new diagnosis of hypertension about dietary modifications. Which of the following recommendations is most effective?
- A. Increase calcium intake.
- B. Reduce saturated fat intake.
- C. Limit carbohydrate intake.
- D. Avoid potassium-rich foods.
Correct Answer: B
Rationale: Reducing saturated fat intake lowers cholesterol and blood pressure, benefiting hypertension management.
The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. Monday and end at 7 a.m. Tuesday?
- A. Collect and save the urine voided at 7 a.m. on Monday.
- B. Send the first voided urine specimen on Monday to the laboratory for culture.
- C. Collect and save the urine voided at 7 a.m. on Tuesday.
- D. Keep each day's urine collection in separate containers.
Correct Answer: C
Rationale: The 24-hour collection includes all urine from after the 7 a.m. Monday void (discarded) to the 7 a.m. Tuesday void (included).
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.