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What should the nurse teach a client with Parkinson's about fall prevention?
- A. Use a walker if unsteady.
- B. Avoid all physical activity.
- C. Wear tight shoes.
- D. Keep lights dimmed.
Correct Answer: A
Rationale: Using a walker if unsteady helps prevent falls in Parkinson's patients with gait instability.
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The nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
A client receiving TPN reports sudden chest pain and dyspnea. Which action should the nurse take first?
- A. Stop the TPN infusion.
- B. Administer oxygen as ordered.
- C. Notify the physician.
- D. Check the client's blood glucose.
Correct Answer: C
Rationale: Sudden chest pain and dyspnea in a client receiving TPN may indicate a serious complication like an air embolism or infection, requiring immediate physician notification. Stopping the infusion or checking glucose is premature, and oxygen requires an order. CN: Physiological adaptation; CL: Synthesize
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following?
- A. The client asks what time the doctor will visit that day.
- B. The client asks about the supplies used during the dressing change.
- C. The client talks about something she read in the morning newspaper.
- D. The client complains about the way the night nurse changed the dressing.
Correct Answer: B
Rationale: The client's inquiry about the supplies used during the dressing change indicates interest and readiness to participate in her colostomy care. Other options reflect unrelated concerns or dissatisfaction, not readiness to engage in self-care. CN: Psychosocial adaptation; CL: Evaluate
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?
- A. timolol
- B. hydroxyzine
- C. phenylephrine
- D. imipramine
Correct Answer: A
Rationale: Timolol, a beta-blocker, reduces intraocular pressure in angle-closure glaucoma by decreasing aqueous humor production. Hydroxyzine, phenylephrine, and imipramine are not used for this condition.