Nokea
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following instructions should the nurse include?
- A. Apply the drops in the morning.
- B. Report any eye pain.
- C. Use the drops every 4 hours.
- D. Avoid regular eye exams.
Correct Answer: B
Rationale: Eye pain may indicate a complication with latanoprost, requiring reporting. Options A, C, and D are incorrect.
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A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
A diagnosis of pernicious anemia is made by:
- A. Bone marrow aspiration
- B. Quantitative assay
- C. Weber test
- D. Schilling test
Correct Answer: D
Rationale: The Schilling test diagnoses pernicious anemia by assessing vitamin B12 absorption. Bone marrow aspiration, quantitative assays, or the Weber test (hearing) are not specific to this condition.
Which clients can be assigned to share the same room?
- A. The client scheduled for a hysterectomy and the client with a tubal ligation
- B. The client with pneumonia and the client just returned from having a cardiac catheterization
- C. The client with AIDS and the client with bronchiectasis
- D. The client with rheumatoid arthritis being treated with steroids and the client with emphysema
Correct Answer: A
Rationale: Clients with hysterectomy and tubal ligation are both post-surgical, non-infectious, and suitable to share a room. Other pairs involve infectious or immunocompromised conditions, posing risks.
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.
The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is
- A. Recurring crises
- B. Continuing drug use
- C. Rationalizing comments
- D. Missing appointments
Correct Answer: B
Rationale: Continuing drug use. Persistent substance use indicates lack of commitment to recovery and ongoing addiction.