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The nurse is caring for a client with a history of glaucoma who is receiving timolol (Timoptic) eye drops. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel a burning sensation when I use the drops.
- B. My heart rate feels slower than usual.
- C. I have a headache in the morning.
- D. My eyes are watery sometimes.
Correct Answer: B
Rationale: Timolol, a beta-blocker, can cause systemic effects like bradycardia, and a slower heart rate is concerning, requiring evaluation to prevent cardiovascular complications. Options A, C, and D are less urgent: burning is common, headaches are nonspecific, and watery eyes are not significant.
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The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
A young woman who is at 32 weeks gestation reports to the physician's office for a routine prenatal visit. Which comment by the woman must be reported to the physician?
- A. I had to stop wearing my rings because my fingers are swollen.'
- B. I seem to be hotter than everyone else.'
- C. My feet tend to swell in the hot weather.'
- D. My breasts are so big and tender.'
Correct Answer: A
Rationale: Finger swelling severe enough to prevent wearing rings may indicate preeclampsia, requiring physician evaluation. Heat sensation, foot edema, and breast changes are normal in pregnancy.
A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome
The nurse is teaching a client with a new diagnosis of asthma about using an albuterol inhaler. Which of the following statements by the client indicates a need for further teaching?
- A. I should shake the inhaler before using it.
- B. I should hold my breath for 10 seconds after inhaling.
- C. I should use the inhaler every 4 hours even if I feel fine.
- D. I should rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Using albuterol every 4 hours without symptoms is incorrect, as it is a rescue inhaler for acute symptoms, not maintenance. Options A, B, and D are correct: shaking ensures proper dose, holding breath maximizes absorption, and rinsing prevents oral thrush (though more relevant for steroids).
The nurse is assisting the RN to develop a nursing care plan for a client who has acute glomerulonephritis. Which of the following should the nurse monitor? Select all that apply.
- A. Urine for protein
- B. Urine for specific gravity
- C. Intake and output
- D. Daily weights
- E. Blood pressure
- F. Serum electrolytes
Correct Answer: A,B,C,D,E,F
Rationale: Glomerulonephritis causes proteinuria, altered urine concentration, fluid retention, hypertension, and electrolyte imbalances; monitoring urine, intake/output, weight, BP, and electrolytes tracks disease progression and complications.