Nokea
The nurse is to Ros instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome?
- A. Dilation of the pupil and blood vessels.
- B. Dilation of the pupil and constriction of blood vessels.
- C. Constriction of the pupil and constriction of blood vessels.
- D. Constriction of the pupil and dilation of blood vessels.
Correct Answer: B
Rationale: Phenylephrine hydrochloride (Neo-Synephrine) is a sympathomimetic agent used to dilate the pupil (mydriasis) by stimulating the dilator muscle of the iris and to constrict blood vessels, reducing conjunctival redness and swelling before cataract surgery.
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A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is:
- A. Arteriosclerosis
- B. Aneurysm formation
- C. Deep vein thrombosis (DVT)
- D. Varicose veins
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a common cause of pulmonary embolism, as clots from the veins (often legs) can dislodge and travel to the lungs, causing acute shortness of breath. Arteriosclerosis, aneurysms, and varicose veins are less directly associated.
Which pressure point area(s) should the nurse monitor for an unconscious client positioned on the left side?
- A. Ankles.
- B. Ear.
- C. Greater trochanter.
- D. Heels.
- E. Occiput.
- F. Sacrum.
- G. Shoulder.
Correct Answer: B,C,D,G
Rationale: On the left side, pressure points include the ear (B), greater trochanter (C), heels (D), and shoulder (G). Ankles, occiput, and sacrum are less affected in this position.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.
The nurse is working with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. Which of the following is an appropriate nursing intervention?
- A. Refer the client to a community support group after discharge from the rehabilitation unit.
- B. Make certain that a family member is present for the rehabilitation sessions.
- C. Provide positive reinforcement for skills achieved.
- D. Inform the client of rehabilitation plans made by the rehabilitation team.
Correct Answer: C
Rationale: Providing positive reinforcement for achieved skills encourages the client's motivation and independence in activities of daily living.