Nokea
The nurse is caring for a client who has been diagnosed with macular degeneration. Which of the following images represent the visual field of a client with macular degeneration?
- A. Qstn 14-A Visual.png
- B. Qstn 14-B Visual.png
- C. Qstn 14-C Visual.png
- D. Qstn 14-D Visual.png
Correct Answer:
Rationale: Macular degeneration causes central vision loss, so the image would show a blurred or dark central area with intact peripheral vision. Specific image selection is not applicable here due to lack of image options.
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Which is a priority assessment for the client in shock who is receiving an I.V. infusion of packed red blood cells and normal saline solution?
- A. Fluid balance.
- B. Anaphylactic reaction.
- C. Pain.
- D. Altered level of consciousness.
Correct Answer: B
Rationale: During a blood transfusion in a client in shock, the priority assessment is for an anaphylactic reaction, as transfusion reactions can be life-threatening and require immediate intervention. Fluid balance, pain, and consciousness are monitored but are secondary.
A nurse is preparing to administer furosemide intravenously to a client. Which action should the nurse perform before administering this medication?
- A. Insert an indwelling urinary catheter.
- B. Review the client's most recent pulse
- C. Establish continuous pulse oximeter monitoring
- D. Assess the client's serum electrolytes
Correct Answer: D
Rationale: Furosemide can cause electrolyte imbalances, so assessing serum electrolytes is critical before administration.
Atropine sulfate (Atropine) is contraindicated in all but which one of the following clients?
- A. A client with diabetes.
- B. A client with glaucoma.
- C. A client with urine retention.
- D. A client with bowel obstruction.
Correct Answer: A
Rationale: Atropine is contraindicated in glaucoma (increases intraocular pressure), urine retention (worsens retention), and bowel obstruction (reduces motility). It is not contraindicated in diabetes, as it has no direct effect on glucose metabolism.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
During the early phase of burn care the nurse should assess the client for?
- A. Hypernatremia.
- B. Hypomatremia.
- C. Metabolic alkalosis.
- D. Hyperkalemia.
Correct Answer: D
Rationale: In the early phase, cell damage from burns releases potassium, causing hyperkalemia. Sodium levels typically decrease (hyponatremia), and metabolic acidosis is more common due to tissue hypoxia.