Nokea
The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis?
- A. Loss of acuity in the peripheral visual field.
- B. Increased lacrimation, blurred vision.
- C. Conjunctivitis, dilated pupils bilaterally.
- D. Photophobia, loss of a portion of the visual field.
Correct Answer: D
Rationale: bright flashes of light and client stating that portion of visual field is dark are classic symptoms
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The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
An 8-year-old client is returned to the recovery room after a bronchoscopy.
- A. How should the nurse position an 8-year-old client after a bronchoscopy?
- B. In semi-Fowler’s position.
- C. Prone, with the head turned to the side.
- D. With the head of the bed elevated 45° and the neck extended.
- E. Supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position promotes lung expansion and reduces the risk of airway obstruction from edema or secretions post-bronchoscopy. Prone positioning limits respiratory assessment, neck extension risks airway obstruction, and supine does not optimize breathing.
The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome?
- A. Prevent iron deficiency anemia.
- B. Decrease touch to prevent overstimulation.
- C. Provide feedings via gavage to decrease energy expenditure.
- D. Replace vitamins depleted as a result of poor maternal diet.
Correct Answer: D
Rationale: frequently, maternal diet is poor, and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
The nurse is teaching a client about self-administration of insulin. Which of the following sites should the nurse recommend for insulin injection?
- A. Forearm.
- B. Upper arm.
- C. Abdomen.
- D. Lower back.
Correct Answer: C
Rationale: the abdomen is a preferred site for insulin injection due to consistent absorption rates
The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching has been successful?
- A. The dye used in the Test will turn my urine green for about 24 hours.'
- B. I will be put to sleep for this procedure. I will return to my room in two hours.'
- C. This procedure will take about 90 minutes to complete. There will be no discomfort.'
- D. The wires that will be attached to my head and chest will not cause me any pain.'
Correct Answer: C
Rationale: procedure takes approximately 90 minutes, not painful