Nokea
The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.
- A. Blue eyes
- B. Older age
- C. African ethnicity
- D. Diabetes mellitus
- E. Use of contact lenses
Correct Answer: B,C,D
Rationale: Older age, African ethnicity, and diabetes mellitus are known risk factors for primary open-angle glaucoma due to increased intraocular pressure susceptibility. Blue eyes and contact lens use are not established risk factors.
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The nurse is assessing a 42-year-old client with cancer. He has lost 1 lb in 4 weeks. He is taking ondansetron (Zofran) for nausea. He has a temperature of 101°F (38.3°C). The fever is indicative of:
- A. Inadequate nutrition.
- B. New resistance to current antiemetic therapy.
- C. Expected response to chemotherapy treatment.
- D. Infection.
Correct Answer: D
Rationale: A fever of 101°F in a cancer patient, especially during chemotherapy, is most likely indicative of infection, which requires prompt evaluation due to immunosuppression.
When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to:
- A. Help keep him well hydrated.
- B. Dissolve clots that he may have.
- C. Prevent kidney failure.
- D. Treat potential cardiac arrhythmias.
Correct Answer: B
Rationale: Thrombolytic drugs dissolve clots in coronary arteries, restoring blood flow to the myocardium during an MI, reducing infarct size and improving outcomes.
The nurse assesses the client's stoma during the initial postoperative period. Which of the following observations should be reported immediately to the physician?
- A. The stoma is slightly edematous.
- B. The stoma is dark red to purple.
- C. The stoma oozes a small amount of blood.
- D. The stoma does not expel stool.
Correct Answer: B
Rationale: A dark red to purple stoma indicates inadequate blood supply, which is a medical emergency requiring immediate reporting to the physician. Slight edema is expected post-surgery, a small amount of blood oozing is normal, and lack of stool expulsion in the initial period may not be immediately concerning unless other symptoms are present. CN: Physiological adaptation; CL: Analyze
The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to:
- A. All other seafood.
- B. Iodine skin preparations.
- C. Caffeine.
- D. Alcohol-based skin preparations.
Correct Answer: B
Rationale: Shellfish allergies are often associated with iodine sensitivity, as shellfish contain iodine. Iodine-based skin preparations used in surgery could trigger an allergic reaction, so this must be assessed. Other options are unrelated to shellfish allergies.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.