Nokea
The nurse is supervising a student administering prescribed ciprofloxacin eye drops. It would indicate the correct technique if the student
- A. instructs the client to squeeze their eyes immediately after administering the drops.
- B. drops the prescribed number of drops into the cornea.
- C. drops the prescribed number of drops into the conjunctival sac.
- D. asks the client to position themselves in a left lateral position with the knees bent.
Correct Answer: C
Rationale: Eye drops should be administered into the conjunctival sac to ensure proper absorption and minimize irritation.
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A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, 'How can that be? I'm not imagining all these symptoms!' The nurse's response will be based on which of the following?
- A. Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels.'
- B. A single random blood test cannot provide reliable information about endocrine levels.'
- C. The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern.'
- D. Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.'
Correct Answer: C
Rationale: Cushing's disease disrupts the normal diurnal cortisol rhythm, leading to consistently high levels, which may not be captured in a single morning test.
A client with uric acid stones is prescribed a low-purine diet. Which food is allowed?
- A. Liver.
- B. Chicken.
- C. Apples.
- D. Sardines.
Correct Answer: C
Rationale: Apples are low in purines, suitable for a uric acid stone diet.
A 66-year-old female who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy and appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/minute, and her skin is cold and clammy. These findings would suggest that the nurse should further assess the client for which of the following conditions?
- A. Schizophrenia.
- B. Panic disorder.
- C. Depression.
- D. Delirium.
Correct Answer: D
Rationale: Disheveled appearance, emotional lability, inappropriate responses, and physical symptoms (tachycardia, tachypnea, clammy skin) suggest delirium, a medical emergency requiring urgent assessment.
When preparing a teaching plan for an adult client about general anesthesia induction, which explanation would be most appropriate?
- A. œYour premedication will put you to sleep.'
- B. œYou will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy.'
- C. œYou will receive intravenous medication to make you sleepy.'
- D. œYou will breathe in medication through a facial mask to make you sleepy.'
Correct Answer: C
Rationale: For adults, explaining that intravenous medication induces sleep is accurate and simple, avoiding overwhelming details while addressing the primary method of general anesthesia induction.
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
- A. Compress the nares.
- B. Tilt the head back.
- C. Give the client tissues to collect the fluid.
- D. Administer an antihistamine for postnasal drip.
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.