Nokea
The nurse is caring for a client with a history of glaucoma. Which of the following medications should the nurse expect to administer?
- A. Timolol (Timoptic).
- B. Atropine (Isopto Atropine).
- C. Pilocarpine (Isopto Carpine).
- D. Latanoprost (Xalatan).
Correct Answer: A, C, D
Rationale: Timolol, pilocarpine, and latanoprost are used to reduce intraocular pressure in glaucoma. Atropine is contraindicated as it increases pressure.
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A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with respiratory distress. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position optimizes lung expansion and eases breathing in COPD.
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse's best response?
- A. What has your neighbor been doing that bothers you?'
- B. How long have you been hearing these terrible voices?'
- C. I won't let your neighbor visit, so you'll be safe.'
- D. What exactly are these terrible voices saying to you?'
Correct Answer: D
Rationale: Asking about the content of the voices helps assess the nature of the hallucinations and potential risks, guiding therapeutic intervention.
Which of the following serologic tests should the nurse have on the chart before a client is started on tissue plasminogen activator or alteplase recombinant (Activase)?
- A. Partial thromboplastin time
- B. Potassium level
- C. Lee-White clotting time
- D. Fibrin split product
Correct Answer: A
Rationale: Partial thromboplastin time (PTT) is essential before administering alteplase to assess bleeding risk, as it is a thrombolytic. Potassium levels and other tests are less relevant in this context.
When preparing to draw up 8 units of a short-acting insulin and 20 units of a long-acting insulin in the same syringe, the nurse should:
- A. Inject air in the vial with the long-acting insulin first.
- B. Draw up the long-acting insulin first.
- C. Draw up either insulin first.
- D. Use a high-dose insulin syringe.
Correct Answer: C
Rationale: Either insulin can be drawn up first, as long as air is injected into both vials in the reverse order and clear (short-acting) is drawn before cloudy (long-acting).
When giving a client a tube feeding the nurse should:
- A. Warm the feeding solution before administration.
- B. Place the client in a left side-lying position.
- C. Aspirate residual gastric contents before the feeding and discard.
- D. Verify position of the tube before beginning feeding.
Correct Answer: D
Rationale: Verifying tube position (e.g., via pH testing or X-ray) is critical to ensure safe administration and prevent aspiration.