Exam 4 Pharmacology
A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is the best?
Can you tell me more about the kind of thoughts you are having?
The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information?
Can you tell me what has been helpful to you in the past when coping with stressful events?
A young male patient who is paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?
Change the patient's position at least every 2 hours.
A young adult patient comes to the emergency department with severe chest pain and agitation. Which action should the nurse take first?
Check blood pressure, pulse, and respirations.
Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
Check the patient's class schedule to help decide when the drugs should be taken
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?
Check the patient's oral temperature again in 4 hours.
A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?
Check the patients oxygen saturation.
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?
Clean the perianal area carefully after every bowel movement.
During physical assessment of a patient who has frequent nosebleeds, the nurse finds nasal sores and necrosis of the nasal septum. The nurse should ask the patient specifically about the use of which drug?
Cocaine
Which information will the nurse include for a patient contemplating a cochlear implant?
Cochlear implants require training in order to receive the full benefit.
A young adult female patient who is human immunodeficiency virus (HIV)-positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?
Continue to use contraception while on this medication.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
Crackles heard at the lower scapular border
A 42-year-old woman with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan?
Dim the lights in the patients room.
A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection?
Discard all open or used cosmetics applied near the eyes.
A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistrubtion to the trunk, with wasting of the arms, legs, and face. What instructions will the nurse give to the patient?
Discuss a change in antiretroviral therapy.
To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement?
Discuss the importance of limiting exposure to amplified music.
The nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's risk of lung cancer, which action by the nurse is best?
Discuss the risks associated with cigarettes during every patient encounter.
The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care?
Discussing the need for sexually transmitted infection testing
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
Document the assessment
A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care?
Dysfunctional family processes related to effect of illness on family members
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?
Elevate the ankle above the heart level
Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4 cell count of 800/L and an undetectable viral load. What is the priority nursing intervention at this time?
Encourage adequate nutrition, exercise, and sleep
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem?
Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A patient with Hodgkins lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?
Establish time to take a short walk almost every day.
A 75-year-old patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?
Experiment with volume and hearing ability in a quiet environment initially.
The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would most appropriate for the nurse to take?
Explain to the patient that this is an expected finding
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction?
Fill the irrigation syringe with body-temperature solution.
The occupational health nurse is caring for an employee who is complaining of bilateral eye pain after a cleaning solution splashed into the employees eyes. Which action will the nurse take first?
Flush the eyes with sterile saline.
An alcohol-intoxicated patient with a penetrating wound to the abdomen is undergoing emergency surgery. What will the nurse expect the patient to need during the perioperative period?
Frequent monitoring for bleeding and respiratory complications
When the nurse is taking a health history of a new patient at the ear clinic, the patient states, I have to sleep with the television on. Which follow-up question is most appropriate to obtain more information about possible hearing problems?
Have you noticed ringing in your ears?
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?
Hematuria
The nurse is assessing a 65-year-old patient for presbyopia. Which instruction will the nurse give the patient before the test?
Hold this card and read the print out loud
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?
Hospitalization will be required for several weeks after the stem cell transplant procedure is performed
A patient's 43 cm-long leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?
Hydrocolloid dressing (DuoDerm)
An older adult patient who has been taking alprazolam (Xanax) calls the clinic asking for a refill of the prescription 1 month before the alprazolam should need to be refilled. Which response by the nurse is best?
I am concerned that you may be overusing the Xanax. Let's make an appointment for you to see the doctor.
A patient with a history of heavy alcohol use is diagnosed with acute gastritis. Which statement by the patient indicates a willingness to stop alcohol use?
I am older and wiser now, and I think I can change my drinking behavior.
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
I can buy some aloe vera gel to use on the area.
When obtaining a health history from a 49-year-old patient, which patient statement is most important to communicate to the primary health care provider?
I cant see as far over to the side.
The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?
I rarely have the energy to get out of bed.
Which statement by the patient to the home health nurse indicates a need for more teaching about selfadministering eardrops?
I should keep the medication refrigerated until I am ready to administer the drops.
A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patients treatment?
I take metoprolol (Lopressor) daily for angina.
A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching?
I will clean the ear canal daily with a cotton-tipped applicator.
A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicates that the discharge teaching has been effective?
I will cover up with long-sleeved shirts and pants for the next 5 days.
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.
Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching?
I will remove my contact lenses at bedtime.
Interleukin-2 (IL-2) is used as adjuvant therapy for patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
IL-2 enhances the immunologic response to tumor cells
The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication?
Ibuprofen (Advil) taken for 20 years to treat osteoarthritis
Which information will the nurse include when teaching a patient with keratitis caused by herpes simplex type 1?
Importance of taking all of the ordered oral acyclovir (Zovirax)
The nurse plans postoperative care for a patient who smokes a pack of cigarettes daily. Which goal should the nurse include in the plan of care for this patient?
Improve sleep
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider?
Increase in carcinoembryonic antigen (CEA)
A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?
It is important to participate in a needle-exchange program
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy?
Low serum albumin level
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority?
Maintaining the patient's blood glucose within a normal range
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
Malignant tumors may spread to other tissues or organs.
Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma?
Mannitol (Osmitrol) 100 mg IV
An older adult who takes medications for coronary artery disease has just been diagnosed with asymptomatic chronic human immunodeficiency virus (HIV) infection. Which information will the nurse include in patient teaching?
Many medications have interactions with antiretroviral drugs
A patient admitted to the hospital after an automobile accident is alert and does not appear to be highly intoxicated. The blood alcohol concentration (BAC) is 100 mg/dL (0.11 mg%). Which action by the nurse is most appropriate?
Monitor frequently for anxiety, hyperflexia, and sweating.
A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 162/98, heart rate 142 and irregular, and respirations 32. Which action by the nurse is most important?
Monitor the patient's electrocardiogram (ECG) and vital signs.
A pregnant woman with a history of asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?
Most infants born to HIV-positive mothers are not infected with the virus
A patient who has a history of ongoing opioid abuse is hospitalized for surgery. After a visit by a friend, the nurse finds that the patient is unresponsive with pinpoint pupils. Which prescribed medication will the nurse administer immediately?
Naloxone (Narcan)
A patient who is admitted to the hospital for wound debridement admits to using fentanyl (Sublimaze) illegally. What finding does the nurse expect?
Nausea and diarrhea
Which patient exposure by the nurse is most likely to require post exposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?
Needle stick with a needle and syringe used to draw blood
Assessment of a patients visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding?
OS 20/50; OD 20/40
During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
Obtain more information from the patient about the family history.
A patient with an open leg wound has a white blood cell (WBC) count of 13,500/L and a band count of 11%. What action should the nurse take first?
Obtain wound cultures
The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the right time?
Oral saquinavir (Invirase)
After the nurse receives report, which patient should the nurse assess first?
Patient admitted with cocaine use who has an irregular heart rate of 142 beats/minute
Which information would be most important to help the nurse determine if the patient needs human immunodeficiency virus (HIV) testing?
Patient age
Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
Patient who has had 10 liquid stools in the last 24 hours
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
Patient who is neutropenic and has a temperature of 100.5 F (38.1 C)
The nurse will most likely prepare a mediation teaching plan about antiretroviral therapy (ART) for which patient?
Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis
Which patient arriving at the urgent care center will the nurse assess first?
Patient with acute right eye pain that occurred while using home power tools
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Patient with audible crackles to the midline posterior chest
A patient who is human immunodeficiency virus (HIV)-infected has a CD4 cell count of 400/L. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?
Patient's ability to comply with ART schedule
Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)?
Perform Snellen testing of visual acuity for a patient with a history of cataracts.
When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action?
Place a fall-risk bracelet on the patient.
The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?
Prevention of HIV transmission between sexual partners
A patient with alcohol dependence is admitted to the hospital with back pain following a fall. Twenty-four hours after admission, the patient becomes tumulus and anxious. Which action by the nurse is most appropriate?
Provide a quiet, well-lit environment.
A newly admitted patient complains of waking frequently during the night. The nurse observes the patient wearing a nicotine patch (Nicoderm CQ) on the right upper arm. Which action is best for the nurse to take?
Question the patient about use of the patch at night.
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
Red wound
A patient with a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?
Remind the patient about the need to return for retesting to verify the results.
A patient who received a corneal transplant 2 weeks ago calls the ophthalmology clinic to report that his vision has not improved with the transplant. Which action should the nurse take?
Remind the patient it may take months to restore vision after transplant.
A patient who smokes a pack of cigarettes daily develops tachycardia and irritability on the second day after abdominal surgery. What is the nurse's best action at this time?
Request a prescription for a nicotine replacement agent.
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
Rinse the mouth before and after each meal and at bedtime with a saline solution
A patient with systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?
Rising body temperature
A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care?
Risk for falls related to temporary decrease in stereoscopic vision
During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient?
Risk for ineffective health maintenance related to a anxiety about new leukemia diagnosis
The nurse cares for an agitated patient who was admitted to the emergency department after taking a hallucinogenic drug and attempting to jump from a third-story window. Which nursing diagnosis should the nurse assign as the highest priority?
Risk for injury related to altered perception
The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer?
Roasted chicken
The nurse is completing the admission database for a patient admitted with abdominal pain and notes a history of hypertension and glaucoma. Which prescribed medications should the nurse question?
Scopolamine patch (Transderm Scop) 1.5 mg
A 75-year-old patient is admitted for pancreatitis. Which tool would be the most appropriate for the nurse to use during the admission assessment?
Screening Test-Geriatric Version (SMAST-G)
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
Separation of the proximal wound edges by 1 cm
The nurse is caring for patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?
Serum sodium 126 mEq/L
The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
Shortness of breath
An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take?
Speak normally but more slowly.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
Stage III
A patient who has inhaled cocaine is admitted to the emergency department with palpitations and shortness of breath. What should the nurse do first?
Start oxygen at 4 L/minute.
The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
Stock the patient's room with all the necessary personal protective equipment
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
Stop the infusion if swelling is observed at the site.
Which action should the nurse take when caring for a patient who is receiving chemotherapy and. complains of problems with concentration?
Suggest use of a daily planner and encourage adequate rest and sleep
Which action will the nurse include in the plan of care for a patient with benign paroxysmal positional vertigo (BPPV)?
Teach the patient that canalith repositioning may be used to reduce dizziness.
A patient who has vague symptoms of fatigue, headaches, and a positive test for human immunodeficiency virus (HIV) antibodies using an enzyme immunoassay (EIA) test. What instructions should the nurse give to this patient?
The EIA test will need to be repeated to verify the results.
When caring for patient who is pancytopenia, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?
The UAP assists the patient to use dental floss after eating
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?
The UAP stands by the patient's bed for 30 minutes talking with the patient
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?
The biopsy will help decide the treatment for my enlarged prostate.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
The cancer involves only the cervix
A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patients statement is
The drops are uncomfortable, but it is important to use them to retain your vision.
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?
The family member dries the wound using a hair dryer set on a low setting
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?
The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide
The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?
The nurse encourages the patient to cough.
Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider?
The patient complains of a curtain over part of the visual field.
Which information is most important for the nurse to report to the health care provider about a patient who has using varenicline (Chantix)?
The patient complains of new-onset sadness and depression
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider?
The patient has a temperature of 100.6 F.
A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4 T-cell count of less than 200 cells/mL. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?
The patient has developed acquired immunodeficiency syndrome (AIDS).
The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider?
The patient has eye pain rated at a 5 (on a 0 to 10 scale).
The nurse is performing an eye examination on a 76-year-old patient. The nurse should refer the patient for a more extensive assessment based on which finding?
The patient reports persistent photophobia.
The nurse cares for a patient who is human immunodeficiency virus (HIV)-positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?
The patient states, "Sometimes I miss a dose of zidovudine (AZT)."
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?
The patient swims a mile 3 days a week
The nurse at the outpatient surgery unit obtains the following information about a patient who is scheduled for cataract extraction and implantation of an intraocular lens. Which information is most important to report to the health care provider at this time?
The patient takes 2 antihypertensive medications.
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
The patient takes insulin daily
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
After receiving a change-of-shift report, which patient should the nurse assess first?
The patient who has been receiving chemotherapy and has a temperature of 102 F
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?
The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include the plan of care?
The patient will maintain intact perineal skin.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
The patient's visitors bring in some fresh peaches from home.
Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider?
The patients oral temperature is 100.8 F (38.1 C).
A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan?
The purpose of maintaining the head in a prescribed position
The nurse should report which assessment finding immediately to the health care provider?
The tympanum is blue-tinged.
A patient presents to the emergency department with a blood alcohol concentration (BAC) of 0.18%. After reviewing the medication orders, which drug should the nurse administer first?
Thiamine (vitamin B1) 100 mg daily
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debunking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
Tumor size will decrease and this will improve the effects of other therapy
Which equipment will the nurse obtain to perform a Rinne test?
Tuning fork
Unlicensed assistive personnel (UAP) perform all the following actions when caring for a patient with Meniere's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should interveneimmediately?
UAP turn on the patients television.
A young adult patient scheduled for an annual physical examination arrives in the clinic smelling of cigarette smoke and carrying a pack of cigarettes. Which action will the nurse plan to take?
Urge the patient to quit smoking as soon as possible.
Which action could the registered nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)?
Use a Snellen chart to check a patients visual acuity.
The nurse in the eye clinic is examining a 67-year-old patient who says I see small spots that move around in front of my eyes. Which action will the nurse take first?
Use an ophthalmoscope to examine the posterior eye chambers.
To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?
Viral load testing
The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction?
Wash hands frequently and avoid touching the eyes.
A patient admitted with shortness of breath and chest pain who is a pack-a-day smoker tells the nurse, "I am just not ready to quit smoking yet." Which response by the nurse is the best?
What health problems do you think smoking has caused?
Which teaching point should the nurse plan to include when caring for a patient whose vision is corrected to 20/200?
Where to obtain specialized magnifiers
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
White blood cell (WBC) count of 2700/L
A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?
Why don't we talk about the options you have for the care of your children?
Which information will the nurse provide to the patient scheduled for refractometry?
You will need to wear sunglasses for a few hours after the exam.
A patient who has undergone a left tympanoplasty should be instructed to
avoid blowing the nose.
The nurse evaluates that wearing bifocals improved the patients myopia and presbyopia by assessing for a. strength of the eye muscles.
both near and distant vision.
The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. The nurse will need to intervene if the student
chooses a speculum larger than the ear canal.
The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease
encouraging the patient to ambulate independently.
The nurse learns that a newly admitted patient has functional blindness and that the spouse has cared for the patient for many years. During the initial assessment of the patient, it is most important for the nurse to
make eye contact with the patient and ask about any need for assistance.
To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by
noting any changes in the patients visual field.
In reviewing a 55-year-old patients medical record, the nurse notes that the last eye examination revealed an intraocular pressure of 28 mm Hg. The nurse will plan to assess
peripheral vision.
A patient arrives in the emergency department complaining of eye itching and pain after sleeping with contact lenses in place. To facilitate further examination of the eye, fluorescein angiography is ordered. The nurse will teach the patient to
report any burning or pain at the IV site.
The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is
risk for falls related to dizziness.
A patient complains of dizziness when bending over and of nausea and dizziness associated with physical activities. The nurse will plan to teach the patient about
rotary chair testing.
When assessing a patients consensual pupil response, the nurse should
shine a light into one pupil and observe the response of both pupils.
The nurse is testing the visual acuity of a patient in the outpatient clinic. The nurses instructions for this test include asking the patient to
stand 20 feet from the wall chart.
The nurse performing an eye examination will document normal findings for accommodation when
the pupils constrict while fixating on an object being moved closer to the patients eyes.
During the preoperative assessment of the patient scheduled for a right cataract extraction and intraocular lens implantation, it is most important for the nurse to assess
the visual acuity of the patients left eye.
A nurse should instruct a patient with recurrent staphylococcal and seborrheic blepharitis to
use a gentle baby shampoo to clean the lids as needed.
When assisting a blind patient in ambulating to the bathroom, the nurse should
walk slightly ahead of the patient and allow the patient to hold the nurses elbow.
When teaching a patient about the treatment of acoustic neuroma, the nurse will include information about
ways to avoid falls.
A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions?
- Administer IV antibiotics - Administer acetaminophen (Tylenol) - Sponge patient with cool water - Perform wet to dry dressing change
The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan?
- Continue taking antibiotics until all medication is gone - Antibiotics may sometimes be prescribed to prevent infection - Hand washing is effective in preventing many viral and bacterial infections.
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan?
- Cook food thoroughly before eating - Avoid public transportation such as buses - Talk to the oncologist before having any dental work done
According to the Center for Disease Control (CDC) guidelines, which personal protective equipment will the nurse put on when assessing a patient who is on contact precautions for diarrhea caused by Clostridium difficile?
- Gown - Gloves
The nurse cares for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care?
- Hepatitis B vaccine - Pneumococcal vaccine - Influenza virus vaccine
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk?
- Pap testing - Sunscreen use - Mammography - Colorectal screening
A patient is admitted to the emergency department for treatment of a possible opioid overdose. Rank the nursing activities in the correct order from first activity to last activity.
- Provide respiratory support with a bag valve mask - Initiate IV access - Administer naloxone (Narcan) - Obtain toxicology screen - Take a health history
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
24-year-old patient who received neck radiation and has blood oozing from the neck
The nurse working in the vision and hearing clinic receives telephone calls from several patients who want appointments in the clinic as soon as possible. Which patient should be seen first?
71-year-old who has noticed increasing loss of peripheral vision
The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing?
A Tono-pen will be applied to the surface of the eye.
The nurse should plan to use a wet-to-dry dressing for which patient?
A patient who has a wound with purulent drainage and dry brown areas
After receiving change-of-shift report on four patients who are undergoing substance abuse treatment, which patient will the nurse assess first?
A patient who has terms secondary to benzodiazepine withdrawal and whose last benzodiazepine use was 4 days ago.
Which assessment finding would alert the nurse to ask the patient about alcohol use?
Abdominal tenderness
Which nursing activity can the nurse delegate to unlicensed assistive personnel (UAP) who are working in a family practice clinic?
Administer and score the Alcohol Use Disorders Identification Test (AUDIT)
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate?
Administer prescribed antiemetics 1 hour before the treatments.
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer?
Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
Which topic will the nurse teach after a patient has had outpatient cataract surgery and lens implantation?
Administration of corticosteroid eye drops
A patient who has bacterial endophthalmitis in the left eye is restless, frequently asking whether the eye is healing, and whether removal of the eye will be necessary. Based on the assessment data, which nursing diagnosis is most appropriate at this time?
Anxiety related to the possibility of permanent vision loss
Which nursing activity is appropriate for the registered nurse (RN) working in the eye clinic to delegate to experienced unlicensed assistive personnel (UAP)?
Application of a warm compress to a patients hordeolum
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
Apply the ordered anesthetic gel to oral lesions before meals.
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?
Ask about fatigue or feelings of malaise.
Which action should the nurse take when providing patient teaching to a 76-year-old with mild presbycusis?
Ask for permission to turn off the television before teaching
A 75-year-old patient who lives alone at home tells the nurse, I am afraid of losing my independence because my eyes dont work as well they used to. Which action should the nurse take first?
Ask the patient more about what type of vision problems are being experienced.
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
Assess for sensation and strength in the legs
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate?
Avoid giving the patient foods that are strongly disliked
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
Blueberry yogurt
Which assessment finding alerts the nurse to provide patient teaching about cataract development?
Blurred vision and light sensitivity
