Nokea
The nurse is caring for an elderly female client in an extended care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate?
- A. provide written materials to explain medications
- B. stand in front of the client when addressing her
- C. limit room lighting to create a relaxed environment
- D. encourage use of radio and CDs
Correct Answer: B
Rationale: Standing in front of the client maximizes her ability to see the nurse, as dry AMD affects central vision, making clear visual communication essential.
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The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?
- A. Apply pressure to the inner canthus after instilling drops.
- B. Instill the drops directly onto the cornea.
- C. Shake the bottle vigorously before use.
- D. Store the drops in the refrigerator.
Correct Answer: A
Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Correct Answer: A
Rationale: Children with myelomeningocele are at higher risk for latex allergy due to repeated exposure to latex products during medical procedures.
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.