Nokea
The nurse is assessing a client who has a long history of uncontrolled hypertension. The nurse should assess the client for damage in which area of the eye?
- A. Iris.
- B. Cornea.
- C. Retina.
- D. Sclera.
Correct Answer: C
Rationale: Uncontrolled hypertension can cause retinopathy, damaging the retina, which should be assessed.
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The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure?
- A. This is done under general anesthesia.
- B. This procedure is rarely associated with complications.
- C. It may cause congestion when clots get trapped at the filter.
- D. This could possibly eliminate the need for anticoagulant therapy.
Correct Answer: A
Rationale: The percutaneous approach uses local anesthesia. Complications after insertion of an IVC filter are rare. When they do occur, they include air embolism, improper placement, and filter migration. Venous congestion can occur from accumulation of thrombi on the filter, but the process usually occurs gradually. There is usually no need for anticoagulant therapy after surgery.
Which neurological complication can occur when a vest restraint is too tight around the client's body?
- A. Strangulation
- B. Skin breakdown
- C. Skin pallor
- D. Numbness
Correct Answer: A
Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.
How many mLs will you administer to the client after you use 3.3 mL of normal saline to reconstitute a medication that will yield 12 mg per mL and the doctor's order is as follows. Doctor's order: 25 mg of medication BID
- A. 1.9 mL
- B. 2.0 mL
- C. 2.5 mL
- D. 2.1 mL
Correct Answer: D
Rationale: To calculate: 25 mg ÷ 12 mg/mL = 2.083 mL, rounded to 2.1 mL for practical administration.
A client is taking ciprofloxacin (Cipro). Which of the following laboratory studies will not be affected by ciprofloxacin?
- A. Theophylline level.
- B. Prothrombin time (PT).
- C. Partial thromboplastin time (PTT).
- D. Total iron-binding capacity.
Correct Answer: D
Rationale: Ciprofloxacin does not typically affect total iron-binding capacity, unlike theophylline levels (drug interaction) or coagulation studies (PT/PTT).
A client is receiving heparin therapy for a pulmonary embolism. The nurse should monitor the client for which of the following adverse effects?
- A. Thrombocytopenia.
- B. Hyperkalemia.
- C. Hypoglycemia.
- D. Hypertension.
Correct Answer: A
Rationale: Heparin can cause heparin-induced thrombocytopenia, a serious adverse effect that reduces platelet count and increases clotting risk, requiring close monitoring.