Nokea
Which intervention is most effective for a client with MS-related vision impairment?
- A. Provide bright lighting.
- B. Use large-print materials.
- C. Limit visual activities.
- D. Wear dark glasses.
Correct Answer: B
Rationale: Large-print materials support clients with MS-related vision impairment by improving readability.
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A client developed shock after a severe myocardial infarction and has now developed acute renal failure. The nurse should base the response on the knowledge that there was:
- A. A decrease in the blood flow through the kid-
- B. An obstruction of urine flow from the kidneys.
- C. A blood clot formed in the kidneys.
- D. A structural damage to the kidney resulting in acute tubular necrosis.
Correct Answer: A
Rationale: Decreased renal blood flow from shock post-myocardial infarction reduces kidney perfusion, leading to acute renal failure.
A 75-year-old client who has been taking furosemide (Lasix) regularly for 4 months tells the nurse that he is having trouble hearing. What would be the nurse's best response to this statement?
- A. Tell the client that because he is 75 years old, it is inevitable that his hearing should begin to deteriorate.
- B. Have the client immediately report the hearing loss to his physician.
- C. Schedule the client for audiometric testing and a hearing aid.
- D. Tell the client that the hearing loss is only temporary; when his system adjusts to the furosemide, his hearing will improve.
Correct Answer: B
Rationale: Furosemide can cause ototoxicity, leading to hearing loss. The nurse should advise the client to report this to the physician promptly for further evaluation and management.
The nurse is caring for a client receiving hydromorphone via patient-controlled analgesia (PCA). The nurse should prioritize assessing the client's
- A. blood pressure.
- B. pain level.
- C. activity tolerance.
- D. bowel patterns.
Correct Answer: B
Rationale: Pain level is the priority assessment for a client on PCA with hydromorphone to ensure effective pain management and adjust dosing if needed.
Which of the following complications is associated with mechanical ventilation?
- A. Gastrointestinal hemorrhage.
- B. Immunosuppression.
- C. Increased cardiac output.
- D. Pulmonary emboli.
Correct Answer: D
Rationale: Mechanical ventilation increases the risk of pulmonary emboli due to immobility and hypercoagulability. Gastrointestinal hemorrhage, immunosuppression, and increased cardiac output are less directly related.
The postoperative nursing assessment of a client's ability to swallow fluids before providing oral fluids is based on the type of anesthesia given. Which of the following clients would not have delayed fluid restrictions?
- A. The client who has undergone a bronchoscopy under local anesthesia.
- B. The client who has undergone a transurethral resection of a bladder tumor under general anesthesia.
- C. The client who has undergone a repair of carpal tunnel syndrome under local anesthesia.
- D. The client who has undergone an inguinal herniorrhaphy with spinal and intravenous conscious sedation.
Correct Answer: A,C
Rationale: Local anesthesia (bronchoscopy, carpal tunnel repair) does not affect swallowing reflexes, so fluids are not delayed. General or spinal anesthesia (B, D) impairs swallowing, requiring delayed fluid intake.