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The nurse is caring for a client with a history of glaucoma who is prescribed timolol (Timoptic) eye drops. The nurse should instruct the client to report which of the following side effects?
- A. Blurred vision.
- B. Bradycardia.
- C. Eye redness.
- D. Dry eyes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, which should be reported immediately.
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The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should:
- A. Have the client walk at least twice a day
- B. Insert an indwelling urinary catheter
- C. Monitor serum albumin
- D. Monitor the white blood cell count
Correct Answer: C
Rationale: Monitoring serum albumin assesses nutritional status, which is critical for skin integrity and preventing pressure ulcers. Walking is contraindicated for bed rest, catheters increase infection risk, and white blood cell count is less relevant.
The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?
- A. Pain relief with knee flexion.
- B. Rebound tenderness in the right lower quadrant.
- C. Increased bowel sounds.
- D. Absence of fever.
Correct Answer: B
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis due to peritoneal irritation.
A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is:
- A. Hospice Association.
- B. Visiting Nurses' Association (VNA).
- C. Meals on Wheels.
- D. American Association of Retired Persons (AARP).
Correct Answer: C
Rationale: Meals on Wheels provides home-delivered meals, which directly addresses the client's difficulty with cooking. Hospice is for end-of-life care, VNA focuses on nursing services, and AARP offers advocacy, not meal services.
Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
- A. Deficient fluid volume
- B. Impaired skin integrity
- C. Acute pain
- D. Impaired gas exchange
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
- A. External.
- B. Cyanosis.
- C. Dyspnea.
- D. Weight loss.
Correct Answer: C
Rationale: Dyspnea indicates inadequate oxygenation, suggesting the activity level may be too strenuous for the client's cardiac capacity post-myocardial infarction.