Med Surg I Exam 4 Practice Q's

676. During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? 1. Call the surgeon. 2. Reassure the client that this is normal. 3. Turn the client onto her or his operative side. 4. Administer the prescribed pain medication and antiemetic.

1. Call the surgeon. Rationale: Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the surgeon immediately. Options 2, 3, and 4 are inappropriate actions. Test-Taking Strategy: Note the strategic word, initial, and the word severe. Eliminate option 2 because this is not a normal condition. The client should not be turned to the operative side; therefore, eliminate option 3. From the remaining options, focusing on the strategic word will direct you to the correct option.

431. The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. Partial-thickness skin loss of the dermis Rationale: In a stage II pressure injury, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulceration with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV. Test-Taking Strategy: Focus on the subject, assessment of a pressure injury. Focusing on the words stage II and visualizing the appearance of a stage II pressure injury will direct you to the correct option.

139. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. Lying in bed on the affected side 2. Lying in bed on the unaffected side 3. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2. Lying in bed on the unaffected side Rationale: To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure. Test-Taking Strategy: Focus on the subject, positioning for thoracentesis. To perform a thoracentesis safely, the site must be visible to the primary health care provider (PHCP) performing the procedure. The client should be placed in a position where he or she is as comfortable as possible with access to the affected side. A prone position would not give the PHCP access to the chest. Lying on the affected side would prevent access to the site.

694. The nurse is caring for a hearing-impaired client. Which approach will facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak at a normal volume. 4. Speak directly into the impaired ear.

3. Speak at a normal volume. Rationale: Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. Test-Taking Strategy: Focus on the subject, an effective communication technique for the hearing impaired. Remember that it is important to speak in a normal tone.

700. Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate

4. Atropine sulfate Rationale: Options 1 and 2 are miotic agents used to treat glaucoma. Option 3 is an anti-infective medication used to treat bacterial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic (also anticholinergic) medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Test-Taking Strategy: Focus on the subject, the medication that the nurse should question. Recalling the classifications of the medications identified in the options will assist in answering the question. Remember that mydriatics dilate the pupil and that these medications are contraindicated in glaucoma.

696. The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eye drop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.

1. Wash hands. 2. Put gloves on. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. Rationale: To administer eye medications, the nurse should wash hands and put gloves on. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication. Test-Taking Strategy: Focus on the subject, the procedure for administering eye drops. Use guidelines related to standard precautions and visualize this procedure. This will assist in determining the correct interventions.

425. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1. An inflammation of the epidermis only 2. A skin infection of the dermis and underlying hypodermis 3. An acute superficial infection of the dermis and lymphatics 4. An epidermal and lymphatic infection caused by Staphylococcus

2. A skin infection of the dermis and underlying hypodermis Rationale: Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics. The infection is not superficial and extends deeper than the epidermis. Test-Taking Strategy: Eliminate options 3 and 4 because they are comparable or alike and address the lymphatics. Eliminate option 1 because of the closed-ended word "only."

350. The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition? 1. The child has difficulty hearing. 2. The child consistently tilts the head to see. 3. The child does not respond when spoken to. 4. The child consistently turns the head to hear.

2. The child consistently tilts the head to see. Rationale: Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. Options 1, 3, and 4 are not indicative of this condition. Test-Taking Strategy: Eliminate options 1 and 4 first because they are comparable or alike and relate to hearing. To select from the remaining options, recall that this is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles.

438. A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide

3. Vitamin A Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide. Test-Taking Strategy: Focus on the subject, the need to contact the PHCP to ensure client safety. Recall that isotretinoin is a metabolite of vitamin A. Vitamin A is a fat-soluble vitamin, and therefore it is possible to develop toxic levels. This will direct you to the correct option.

423. The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first-priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity. 2. Remove jewelry and constricting clothing from the victim. 3. Place the extremity in a position so that it is below the level of the heart. 4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4. Move the victim to a safe area away from the snake and encourage the victim to rest. Rationale: In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as possible. Test-Taking Strategy: Note the strategic words, first priority. Eliminate options 1 and 3 first because they are comparable or alike and relate to positioning of the affected extremity. For the remaining options, think about them and visualize each. Moving the victim to a safe area is the priority to prevent further injury from the snake.

What assessment data are most important in completing a history and physical examination of the eye? A. Family history, current state of health B. Record of daily food intake, obtaining an accurate weight of the patient C. Medications taken daily and occupation D. Use of sun protective glasses on a daily basis and immunization history

A. Family history, current state of health Family history and general state of health are closely associated with eye/visual health. Weight is not generally associated with eye health. Medications and occupation may be relevant, but not as essential to history. Use of sunglasses is more closely related to potential damage to the eye.

The nurse must consider all of these assessments prior to preparing a patient for diagnostic studies of the eye. Which intervention can be delegated to the technician on the team? A. Assessing the patient's past medical history B. Administering preprocedure medications C. Obtaining an accurate height and weight of the patient D. Reviewing current medications patient is taking daily

C. Obtaining an accurate height and weight of the patient Technicians and nurse extenders may obtain heights and weights. The other interventions require a licensed or registered nurse.

A nurse caring for a pt who has contact dermatitis & has a new RX for diphenhydramine. For which of the following adverse effects should the nurse monitor? a. Elevated blood glucose levels b. Anorexia c. Increased salivation d. Insomnia

b. Anorexia Monitor the pt for anorexia, which is a possible adverse effect of diphenhydramine a. Elevated blood glucose levels Glucocorticoids (prednisone) can increase blood glucose levels. However, this isn't an adverse effect of diphenhydramine c. Increased salivation Increased salivation ins't an adverse effect of diphenhydramine. Monitor pt for dry mouth d. Insomnia diphenhydramine is a 1st generation antihistamine & can cause excessive drowsiness rather than insomnia

A nurse is educating a client on the use of calcipotriene topical mediation for the tx of psoriasis. Which of the following lab values should the nurse monitor? a. Potassium b. Calcium c. Sodium d. Chloride

b. Calcium Hypercalcemia is a possible adverse effect of calcipotriene a. Potassium Calcipotriene doesn't cause hypokalemia or hyperkalemia c. Sodium Calcipotriene doesn't cause hyponatremia or hypernatremia d. Chloride Calcipotriene doesn't cause hypochloremia or hyperchloremia

A nurse is caring for a male older adult patient who has a new diagnosis of glaucoma . Which of the following should the nurse recognize as risk factor associated with this disease? (SATA) a. Sex b. Genetic predisposition c. Hypertension d. Age e. Diabetes Mellitus

b. Genetic predisposition Genetic predisposition is a risk factor associated with glaucoma c. Hypertension This is a risk factor associated with glaucoma d. Age Age is a risk factor associated with glaucoma e. Diabetes Mellitus Diabetes mellitus is a risk factor associated with glaucoma a. Sex Sex is not a risk factor associated with glaucoma

A clinical diagnosis of open-angle glaucoma is more likely to be associated with which ethnic group? Caucasian African Americans Mexican Americans Hispanic Americans

African Americans

Which technique would lead to increased eye absorption of medications used in the treatment of glaucoma? Encourage the client to drink fluids following administration of medication. Apply gentle pressure to the client's nasolacrimal duct for 30 to 60 seconds. Position the client on the affected side to increase absorption post administration. Instruct the client to refrain from coughing.

Apply gentle pressure to the client's nasolacrimal duct for 30 to 60 seconds.

344. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye as prescribed." 3. "It is okay to share towels and washcloths." 4. "I need to give the eye drops as prescribed."

3. "It is okay to share towels and washcloths." Rationale: Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths. Options 1, 2, and 4 are correct treatment measures. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Options 1, 2, and 4 can be eliminated by recalling that bacterial conjunctivitis is highly contagious.

681. The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? 1. Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4. Blurred vision Rationale: A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract. Test-Taking Strategy: Note the strategic word, early. Remember the pathophysiology related to cataract development. As a cataract develops, the lens of the eye becomes opaque. This description will assist in directing you to the correct option.

686. A woman was working in her garden. She accidentally sprayed insecticide into her right eye. She calls the emergency department, frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. Irrigate the eyes with water. 2. Come to the emergency department. 3. Call the primary health care provider (PHCP). 4. Irrigate the eyes with diluted hydrogen peroxide.

1. Irrigate the eyes with water. Rationale: In this type of accident, the client is instructed to irrigate the eyes immediately with running water for at least 20 minutes, or until the emergency medical services personnel arrive. In the emergency department, the cleansing agent of choice is usually normal saline. Calling the PHCP and going to the emergency department delays necessary intervention. Hydrogen peroxide is never placed in the eyes. Test-Taking Strategy: Note the strategic word, immediate. Focus on the type of injury and eliminate options 2 and 3 because they delay necessary intervention. Next, eliminate option 4 because hydrogen peroxide is never placed in the eyes.

691. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Avoid sudden head movements. 3. Lie still and watch the television. 4. Increase fluid intake to 3000 mL a day.

2. Avoid sudden head movements. Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo. Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the relationship between vertigo and avoiding sudden head movements in the correct option.

677. The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes. 2. Decrease the amount of salt in the diet. 3. Eye medications will need to be administered for life. 4. Decrease fluid intake to control the intraocular pressure.

3. Eye medications will need to be administered for life. Rationale: The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are not accurate instructions. Test-Taking Strategy: Focus on the subject, client teaching for glaucoma. Recalling that medications are an integral component of the treatment plan will assist in directing you to the correct option.

In assessing a patient's vision, the nurse recognizes which structures as key to the visual system? A. Uvea, lacrimal gland, macula B. Eye ball, cochlea, retina C. Fovea, retina, macula D. Rods, ciliary body, aqueous humor

C. Fovea, retina, macula The fovea, retina, and macular are the key structures needed for vision. The lacrimal duct provides moisture, but not directly related to vision. The cochlea is a part of the ear. The aqueous humor helps to provide the structure of the eyeball, but has little role in visual acuity.

687. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over. Test-Taking Strategy: Focus on the subject, postoperative care following eye surgery. Recalling that the eye needs to be protected and that increased IOP is a concern will assist in determining the home care measures to be included in the plan.

439. The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands

1. Back 4. Soles of the feet 5. Palms of the hands Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption. Test-Taking Strategy: Focus on the subject, permeability and the potential for increased systemic absorption. Eliminate options 2 and 3, because these body areas are comparable or alike in terms of skin substance. From the remaining options, think about permeability of the skin area. This should direct you to the correct options.

436. A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site

1. Hyperventilation Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury. Test-Taking Strategy: Note the words systemic ef ect. Options 3 and 4 can be eliminated because they are comparable or alike and are local rather than systemic effects. From the remaining options, recall that the client in pain would likely have an elevated blood pressure. This should direct you to the correct option.

440. The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid to treat acne. The nurse determines that which client complaint may be associated with use of this medication? 1. Itching 2. Euphoria 3. Drowsiness 4. Frequent urination

1. Itching Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication. Test-Taking Strategy: Focus on the subject, an effect associated with the use of azelaic acid. Focusing on the name of the medication and recalling that acne medications commonly cause local irritation will direct you to the correct option.

144. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? 1. Left Sims' position 2. Right Sims' position 3. On the left side of the body, with the head of the bed elevated 45degrees 4. On the right side of the body, with the head of the bed elevated 45 degrees

1. Left Sims' position Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position. Test-Taking Strategy: Focus on the subject, positioning for enema administration. Use knowledge regarding the anatomy of the bowel to answer the question. The descending colon is located on the lower left side of the body. The head of the bed should be flat during enema administration.

351. A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Provide a soft diet 2. Position the child on the left side 3. Administer an antihistamine twice daily 4. Irrigate the right ear with normal saline Q 8 hrs 5. Administer ibuprofen for fever Q4 hours as prescribed & needed 6. Instruct the parents about the need to administer the prescribed ABX for the full course of therapy

1. Provide a soft diet 5. Administer ibuprofen for fever Q4 hours as prescribed & needed 6. Instruct the parents about the need to administer the prescribed ABX for the full course of therapy Rationale: Acute otitis media is an inflammatory disorder caused by an infection of the middle ear. The child often has fever, pain, loss of appetite, and possible ear drainage. The child also is irritable and lethargic and may roll the head or pull on or rub the affected ear. Otoscopic examination may reveal a red, opaque, bulging, and immobile tympanic membrane. Hearing loss may be noted, particularly in chronic otitis media. The child's fever should be treated with ibuprofen. The child is positioned on her or his affected side to facilitate drainage. A soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Antibiotics are prescribed to treat the bacterial infection and should be administered for the full prescribed course. The ear should not be irrigated with normal saline because it can exacerbate the inflammation further. Antihistamines are not usually recommended as a part of therapy. Test-Taking Strategy: Focus on the subject, care for the child with acute otitis media, and on the child's diagnosis and note the words acute and right ear. Think about the pathophysiology associated with the disorder and the associated manifestations to select the correct options.

692. The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye. 3. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

1. The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20 feet (6 meters) from the chart. Test-Taking Strategy: Remember that normal visual acuity as measured by a Snellen chart is 20/20 vision. This should assist in eliminating options 3 and 4, because they are comparable or alike in that they indicate standing at a distance of 40 feet (12 meters). From the remaining options, remember that it is best and most accurate to test each eye separately and then test both eyes together.

433. Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

1. Tinnitus Rationale: Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism. Test-Taking Strategy: Focus on the subject, systemic toxicity. Noting the name of the medication will assist in directing you to the correct option if you can recall the toxic effects that occur with acetylsalicylic acid (aspirin).

697. The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse take when performing the procedure? 1. Warm the irrigating solution to 98.6° F (37.0° C). 2. Position the client with the affected side up following the irrigation. 3. Direct a slow, steady stream of irrigation solution toward the eardrum. 4. Assist the client to turn her or his head so that the ear to be irrigated is facing upward.

1. Warm the irrigating solution to 98.6° F (37.0° C). Rationale: Before ear irrigation, the nurse should inspect the tympanic membrane to ensure that it is intact. The irrigating solution should be warmed to 98.6° F (37.0°C), because a solution temperature that is not close to the client's body temperature will cause ear injury, nausea, and vertigo. The nurse should check the temperature of the solution on the inner forearm. The affected side should be down following the irrigation to assist in drainage of the fluid. When irrigating, a direct and slow steady stream of irrigation solution is directed toward the wall of the canal, not toward the eardrum. The client is positioned sitting, facing forward with the head in a natural position; if the ear is faced upward, the nurse would not be able to visualize the canal. Test-Taking Strategy: Focus on the subject, the procedure for performing ear irrigation. Think about the purpose of this procedure and keep safety in mind. Visualizing each step and the information in the options will assist in eliminating the incorrect ones.

682. A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is diagnosed. The nurse should place the client in which position? 1. Flat in bed 2. A semi-Fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2. A semi-Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea. Test-Taking Strategy: Focus on the subject, care of the client who has sustained a hyphema. Remember that placing the client flat will produce an increase in pressure at the injured site. Also, note that the correct option is the one that identifies a position different from the other options.

146. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

2. Elevate and immobilize the grafted extremity. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site. Test-Taking Strategy: Focus on the subject, positioning after autograft. Use general postoperative principles; elevating the graft site will decrease edema to the graft. The client should not be placed in a prone position or have it covered after surgery, because this can disrupt a graft easily.

693. A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. Provide the client with materials on legal blindness. 2. Instruct the client that he or she may need glasses when driving. 3. Inform the client of where he or she can purchase a white cane with a red tip. 4. Inform the client that it is best to sit near the back of the room when attending lectures.

2. Instruct the client that he or she may need glasses when driving. Rationale: Vision that is 20/20 is normal—that is, the client is able to read from 20 feet (6 meters) what a person with normal vision can read from 20 feet (6 meters). A client with a visual acuity of 20/60 can only read at a distance of 20 feet (6 meters) what a person with normal vision can read at 60 feet (18 meters). With this vision, the client may need glasses while driving in order to read signs and to see far ahead. The client should be instructed to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness. Test-Taking Strategy: Focus on the subject, interpreting a Snellen chart result. Note the test result, 20/60, and recall the associated interventions for this result. Also, eliminate options 1 and 3, as they are comparable or alike, implying that the test results indicate blindness.

428. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. 1. Lesion is painful to touch. 2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color. 4. Skin under the lesion is reddened and warm to touch. 5. Lesion occurs in body areas exposed to outdoor sunlight.

2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color. Rationale: Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. Melanomas cause changes in a nevus (mole), including color and borders. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Melanomas are not painful or accompanied by sign of inflammation. Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are apparent. Test-Taking Strategy: Focus on the subject, characteristics of melanoma skin cancer. It is necessary to know the normal characteristics associated with melanoma to answer this question correctly. Also, recalling that melanomas are highly metastatic will assist in directing you to the correct options.

688. Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops. 2. Note the time of day the test was done. 3. Contact the primary health care provider (PHCP). 4. Instruct the client to sleep with the head of the bed flat.

2. Note the time of day the test was done. Rationale: Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21 mm Hg are considered within the normal range. However, IOP is slightly higher in the morning. Therefore, the initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma. It is not necessary to contact the PHCP as an initial action. Flat positions may increase the pressure. Test-Taking Strategy: Focus on the subject, normal IOP, and note the strategic word, initial. Remember that normal IOP is between 10 and 21 mm Hg and the pressure may be higher in the morning.

142. The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Head elevated lying on the operative side 2. On the nonoperative side with the legs abducted 3. Side-lying with the affected leg internally rotated 4. Side-lying with the affected leg externally rotated

2. On the nonoperative side with the legs abducted Rationale: Positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis. Test-Taking Strategy: Focus on the strategic word, best. Use knowledge regarding care of clients after total hip replacement to answer this question. After a total hip replacement, the client should never have the extremity internally or externally rotated. Lying on the surgical side can cause damage to the surgical replacement site. Focus on the subject, right cataract surgery. Use of the principles of gravity and edema formation will assist in answering this question. Remember to instruct the client to remain off the operative side and to rest with the head elevated to minimize edema formation. This will assist you when answering questions related to cataract surgery.

684. A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. Apply an eye patch. 2. Perform visual acuity tests. 3. Irrigate the eye with sterile saline. 4. Remove the piece of wood using a sterile eye clamp.

2. Perform visual acuity tests. Rationale: If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist, because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. Test-Taking Strategy: Note the strategic word, initial, and note the word penetrating. This should indicate that a laceration has occurred and that interventions are directed at preventing further disruption of the integrity of the eye. The only option that will prevent further disruption is to assess visual acuity.

427. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2. Positive culture results Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. Test-Taking Strategy: Focus on the subject, diagnosing herpes zoster. Recalling that herpes zoster is caused by a virus will assist in directing you to the correct option. Also remember that a biopsy will determine tissue type, whereas a culture will identify an organism.

343. The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? 1. Possible trauma 2. Possible sexual abuse 3. Presence of an allergy 4. Presence of a respiratory infection

2. Possible sexual abuse Rationale: Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Trauma, allergy, and infection can cause conjunctivitis, but the causative organism is not likely to be Chlamydia. Test-Taking Strategy: Note the age of the child and the organism that is identified in the question. Also note that options 1, 3, and 4 are comparable or alike in that they can be recognized as the common causes of conjunctivitis and they relate to a physiological problem.

437. Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Potassium level 2. Triglyceride level 3. Hemoglobin A1C 4. Total cholesterol level

2. Triglyceride level Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A1C, or total cholesterol levels. Test-Taking Strategy: Note the subject, laboratory values that should be monitored specifically for the client taking isotretinoin. Recall that the medication can affect triglyceride levels in the client.

434. The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious.

2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious. Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be applied 30 minutes to 1 hour before sun exposure, and reapplied every 2 to 3 hours, and after swimming or sweating; otherwise, the duration of protection is reduced. Test-Taking Strategy: Focus on the subject, measures to prevent skin cancer. Read each option carefully. Noting the time frames in options 1 and 4 will assist in eliminating these options.

424. A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1. "Come to the emergency department." 2. "Apply calamine lotion immediately to the exposed skin areas." 3. "Take a shower immediately, lathering and rinsing several times." 4. "It is not necessary to do anything if you cannot see anything on your skin."

3. "Take a shower immediately, lathering and rinsing several times." Rationale: When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Removing the poison ivy sap will decrease the likelihood of irritation. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time. Test-Taking Strategy: Focus on the subject, contact with poison ivy. Recalling that dermatitis can develop from contact with an allergen and that contact with poison ivy results in an invisible film will assist in directing you to the correct option.

701. A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1. "The medication will help dilate the eye to prevent pressure from occurring." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3. "The medication causes the pupil to constrict and will lower the pressure in the eye." Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Note that the client has glaucoma. Recall that prevention of increased intraocular pressure is the goal in the client with glaucoma. Options 1, 2, and 4 are comparable or alike and describe actions related to mydriatic medications, which primarily dilate the pupils and relax the ciliary muscles.

702. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3. Acetylsalicylic acid Rationale: Aspirin (acetylsalicylic acid) is contraindicated for GI bleeding and is potentially ototoxic. The client should be advised to notify the prescribing primary health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have effects that are potentially associated with hearing difficulties. Test-Taking Strategy: Focus on the subject, the medication that may be causing the client's complaint. Review the classifications and/or therapeutic effects as well as the side and adverse effects of each medication in the options. Of the medications identified, only aspirin can cause ototoxicity. In addition, it is contraindicated for GI bleed.

141. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3. Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. Test-Taking Strategy: Focus on the subject, the safe position or activity for the client with deep vein thrombosis. Think about the pathophysiology associated with this disorder and the principles related to gravity flow and edema to answer the question.

703. In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action? 1. Provide lubrication to the operative eye prior to giving the eye drops. 2. Call the surgeon, as this medication will further constrict the operative pupil. 3. Consult the surgeon, as there is not sufficient time for the dilative effects to occur. 4. Give the medication as prescribed; the surgeon needs optimal constriction of the pupil.

3. Consult the surgeon, as there is not sufficient time for the dilative effects to occur. Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis, not pupil constriction. The nurse should consult with the surgeon about the time of administration of the eye drops, because 15 minutes is not adequate time for dilation to occur. Test-Taking Strategy: Note the strategic word, initial. Options 2 and 4 are comparable or alike and are eliminated first (miosis refers to a constricted pupil). Note that the question identifies a client being prepared for eye surgery. The pupil would need to be dilated for the surgical procedure.

148. The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low-Fowler's 3. High-Fowler's 4. Supine with the head flat

3. High-Fowler's Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side and low-Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube. Test-Taking Strategy: Focus on the subject, insertion of a nasogastric tube. Visualize each position and think about how it may facilitate insertion of the tube. Also, recall that a concern with insertion of a nasogastric tube is pulmonary aspiration. Placing the client in a high-Fowler's position with his or her chin to the chest will decrease the risk of aspiration.

695. Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1. Assessing for edema 2. Monitoring temperature 3. Monitoring blood pressure 4. Assessing blood glucose level

3. Monitoring blood pressure Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are side and adverse effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 2, and 4 are not specifically associated with this medication Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs— airway, breathing, and circulation—to direct you to the correct option.

685. The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding. 2. Continue to monitor the drainage. 3. Notify the primary health care provider (PHCP). 4. Mark the drainage on the dressing and monitor for any increase in bleeding.

3. Notify the primary health care provider (PHCP). Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the PHCP, because this indicates hemorrhage. Options 1, 2, and 4 are inappropriate at this time. Test-Taking Strategy: Determine if an abnormality exists. Note the words, bright red. Since an abnormality does exist, eliminate options that state to document and continue to monitor because an action is needed.

690. The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. Speak loudly but mumble or slur the words. 2. Speak loudly and clearly while facing the client. 3. Speak at normal tone and pitch, slowly and clearly. 4. Speak loudly and directly into the client's affected ear.

3. Speak at normal tone and pitch, slowly and clearly. Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear. Test-Taking Strategy: Focus on the subject, presbycusis and the effective method to communicate. Visualize each of the communication techniques to direct you to the correct option.

432. The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chickenpox 4. The nurse who never had German measles 5. The nurse who never received the varicella-zoster vaccine

3. The nurse who never had chickenpox 5. The nurse who never received the varicella-zoster vaccine Rationale: The nurses who have not had chickenpox or did not receive the varicella zoster vaccine are susceptible to the herpes zoster virus and should not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus or who did not receive the varicella zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Test-Taking Strategy: Focus on the subject, transmission of herpes zoster. Recalling that herpes zoster is caused by a reactivation of the varicella zoster virus, the causative virus of chickenpox, will direct you to the correct options.

429. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Test-Taking Strategy: Note the strategic words, most likely. Recall characteristics and etiology of basal cell cancer to direct you to the correct options.

679. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? 1. A pink-colored tympanic membrane 2. A pearly colored tympanic membrane 3. A transparent and clear tympanic membrane 4. A red, dull, thick, and immobile tympanic membrane

4. A red, dull, thick, and immobile tympanic membrane Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Test-Taking Strategy: Focus on the subject, the assessment findings in mastoiditis. Think about the pathophysiology associated with mastoiditis and remember that mastoiditis reveals a red, dull, thick, and immobile tympanic membrane.

678. The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4. A sense of a curtain falling across the field of vision Rationale: A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this problem. A retinal detachment is an ophthalmic emergency, and even more so if visual acuity is still normal. Test-Taking Strategy: Focus on the subject, manifestations of retinal detachment. Thinking about the pathophysiology associated with this problem will direct you to the correct option.

430. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nailbeds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

4. A white color to the skin, which is insensitive to touch Rationale: Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect. Test-Taking Strategy: Focus on the subject, assessment findings in frostbite. Noting the words insensitive to touch in the correct option should direct you to this option.

442. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

4. At least 30 minutes before exposure to the sun Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating. Test-Taking Strategy: Knowledge that sunscreens need to penetrate the skin will assist in eliminating options 2 and 3. Next, noting the strategic words, most ef ective, will assist in directing you to the correct option.

147. The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure? 1. Bed rest in high-Fowler's position 2. Bed rest with bathroom privileges only 3. Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4. Bed rest with head elevation no greater than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the primary health care provider's (PHCPs) preference and on whether a vascular closure device was used), and the client may turn from side to side. The head is elevated no more than 30 degrees (although some PHCPs prefer a lower position or the flat position) until hemostasis is adequately achieved. Test-Taking Strategy: Focus on the subject, positioning after cardiac catheterization. Think about this diagnostic procedure and what it entails. Understanding that the head of the bed is never elevated more than 30 degrees and bathroom privileges are restricted in the immediate postcatheterization period will assist in answering this question.

689. The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

4. Cranial nerve VII, facial nerve Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made, because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal. Test-Taking Strategy: Focus on the subject, a complication following surgery. Think about the anatomical location of an acoustic neuroma and the nerves that the neuroma can compress to direct you to the correct option.

698. The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse should instruct the client to take which action? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 4. Occlude the nasolacrimal duct with a finger after instilling the drops.

4. Occlude the nasolacrimal duct with a finger after instilling the drops. Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption. Test-Taking Strategy: Focus on the subject, systemic effects. Eating and swallowing are comparable or alike and are not related to the systemic absorption of eye drops. Blinking vigorously to produce tearing may result in the loss of the administered medication.

145. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

4. Supine, with the residual limb supported with pillows Rationale: The residual limb is usually supported on pillows for the first 24 hours after surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the primary health care provider's or surgeon's prescriptions regarding positioning after amputation, because there are often differences in preference in terms of positioning after the procedure related to risks associated with hip and knee contracture. Test-Taking Strategy: Focus on the subject, positioning after amputation, and note that the client has just returned from surgery. Using basic principles related to immediate postoperative care and preventing edema will assist in directing you to the correct option.

426. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. 1. Presence of striae 2. Palpable radial pulses 3. Absence of any ecchymosis on the extremities 4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms

4. Thinner and decrease in number of reddish papules 5. Scarce amount of silvery-white scaly patches on the arms Rationale: Psoriasis skin lesions include thick reddened papules or plaques covered by silvery-white patches. A decrease in the severity of these skin lesions is noted as an improvement. The presence of striae (stretch marks), palpable pulses, or lack of ecchymosis is not related to psoriasis. Test-Taking Strategy: Focus on the subject, manifestations of psoriasis. Use knowledge regarding the pathophysiology and signs and symptoms associated with psoriasis. This will direct you to the correct options detailing a decrease in the psoriatic signs.

435. Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? 1. Glucose level of 99 mg/dL (5.65 mmol/L) 2. Platelet level of 300,000 mm3 (300 × 109/L) 3. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 4. White blood cell count of 3000 mm3 (3.0 × 109/L)

4. White blood cell count of 3000 mm3 (3.0 × 109/L) Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication and are also within normal limits. Test-Taking Strategy: Note the strategic words, need for follow-up. Eliminate options 1, 2, and 3 because they are comparable or alike and are within normal limits. In addition, recall that leukopenia is an adverse effect requiring discontinuation of the medication.

A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (SATA) A. Limit visitors in the pt's room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the pt to consume 2000calories/day E. Restrict fresh flowers in the room

A. Limit visitors in the pt's room Limit visitors & ensure ill individuals don't visit the pt., to decrease the risk of infection. C. Increase protein intake The pt should increase protein consumption, which promotes wound healing & prevents tissue breakdown E. Restrict fresh flowers in the room Flowers should not be in the pt's room due to bacteria they carry, which increases the risk for infection B. Encourage fresh vegetables in the diet Some facilities restrict consumption of fresh vegetables due to the presence of bacteria on the surface & increased risk for infection D. Instruct the pt to consume 2000calories/day The pt should consume up to 5000calories/day because caloric needs double or triple beginning 4 to 12 days following the burn.

A nurse is caring for a pt who has sustained burns over 35% of total body surface area. The pt's voice has become hoarse, a brassy cough has developed & the pt is drooling. The nurse should identify these findings as indication that the pt has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning

C. Inhalation injury Wheezing & hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider. A. Pulmonary edema difficulty breathing & production of pink frothy sputum indicate pulmonary edema b. Bacterial pneumonia productive cough & a fever are indicative of a bacterial infection d. Carbon monoxide poisoning confusion & headaches indicate carbon monoxide poisoning

A nurse in a clinic is caring for a pt who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (SATA) a. reduce exposure to bright lighting b. move head slowly when changing positions c. do not eat fruit high in potassium d. plan evenly-spaced daily fluid intake e. avoid fluids containing caffeine

a. reduce exposure to bright lighting Remaining in a darkened, quiet environment can reduce vertigo, particularly when it is severe b. move head slowly when changing positions moving slowly when standing or changing positions can reduce vertigo d. plan evenly-spaced daily fluid intake fluid intake should be planned so that it is evenly spaced throughout the day to prevent excess fluid accumulation in the semicircular canals c. do not eat fruit high in potassium The pt who has vertigo should be instructed to avoid foods containing high levels of sodium to reduce fluid retention. e. avoid fluids containing caffeine The client should avoid fluids containing caffeine or alcohol to minimize vertigo

A nurse in a provider's office is assessing a pt who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? a. superficial thickness b. superficial partial thickness c. deep partial thickness d. full thickness

a. superficial thickness A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin. b. superficial partial thickness a superficial partial thickness burn results from flames or scalds. This damages the entire epidermis layer of the skin. c. deep partial thickness A deep partial thickness burn can result from contact with hot grease. This affects the deep layers of the skin. d. full thickness A full thickness burn can result from contact with hot tar. This affects the dermis and sometimes the subcutaneous fat layer.

A nurse is providing discharge instructions to a client who had a skin bx w/ sutures. The nurse should identify that which of the following client statements indicates that the teaching has been effective? a. "I can expect redness around the site for 5-7 days" b. "I will most likely have a fever for the first few days" c. "I should apply an ABX ointment to the area." d "I will make a return appt. in 3 days for removal of my sutures."

c. "I should apply an ABX ointment to the area." ABX ointment is applied as prescribed by the provider to prevent infection a. "I can expect redness around the site for 5-7 days" The client should report redness, pain, drainage or warmth at the biopsy site to the provider b. "I will most likely have a fever for the first few days" A fever is an indication of an infection, and the provider should be notified d "I will make a return appt. in 3 days for removal of my sutures." Removal of the sutures following a biopsy is done 7-10 days post procedure

A nurse is providing teaching to a client about a new prescription for clotrimazole topical cream. Which of the following statements should the nurse include? a. "it reduces the discomfort of a herpetic infection but does not cure the infection" b. "this is a cream to treat a bacterial infection." c. "apply the topical medication for up to 2 weeks after the fungal lesions are gone." d. "apply the cream to lesions whole they are moist."

c. "apply the topical medication for up to 2 weeks after the fungal lesions are gone." Clotrimizole is a medication used to treat fungal infection and is applied for 1-2 weeks after the infection is resolved. a. "it reduces the discomfort of a herpetic infection but does not cure the infection" Clotrimazole is not an antiviral medication to treat a herpetic infection b. "this is a cream to treat a bacterial infection." Clotrimazole is not an antibacterial infection d. "apply the cream to lesions whole they are moist." Clotrimazole should be applied to clean, dry skin. Wash the skin gently & pat dry before applying

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (SATA) a. Eye pain b. Floating spots c. Blurred vision d. White pupils e. Bilateral red reflexes

c. Blurred vision Blurred vision is a manifestation associated with cataracts. d. White pupils White pupils is a manifestation associated with cataracts. a. Eye pain Eye pain is a manifestation associated with primary angle-closure glaucoma b. Floating spots Floating spots are a manifestation associated with retinal detachment. e. Bilateral red reflexes Bilateral red reflexes are absent in a client who has cataracts.

A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? a. Use fabric softener dryer sheets when drying the child's clothes b. Apply a warm, dry compress to the rash area c. Place the child in a bath with colloidal oatmeal d. Leave the child's hands uncovered during the night

c. Place the child in a bath with colloidal oatmeal The use of colloidal oatmeal bath will relieve the child's itching a. Use fabric softener dryer sheets when drying the child's clothes The guardian should avoid the use of fabric softener dryer sheets when cleaning the child's clothing. Liquid fabric softener can be used. b. Apply a warm, dry compress to the rash area The guardian should apply a cool, moist compress to the child's rash are to decrease inflammation d. Leave the child's hands uncovered during the night The guardian should apply mittens on the child's hands at night to decrease unconscious scratching of the rash, which can lead to a secondary infection

A nurse is caring for a client who has suspected viral skin lesion. Which of the following lab findings should the nurse expect to review to confirm this DX? a. potassium hydroxide (KOH) b. diascopy c. Tzanck smear report d. biopsy

c. Tzanck smear report a tzanck smear report confirms whether a skin lesion is viral in origin a. potassium hydroxide (KOH) Findings of (KOH) test reveal if skin lesions are fungal in origin b. diascopy diascopy provides increased visibility of a skin lesion by blanching the skin over the lesion, thus eliminating erythema which can obscure findings d. biopsy Findings of a biopsy report confirm or rule out if a lesion is malignant

A nurse is instructing a client with on home care after a culture for a bacterial infection & cellulitis. Which of the following information should the nurse include? a. bathe daily with moisturizing soap b. apply antibacterial topical medication to the crusted exudate c. apply warm compresses to the affected area d. cover affected area with snug fitting clothing

c. apply warm compresses to the affected area The client should apply warm compresses to the effected area to promote comfort a. bathe daily with moisturizing soap The client should use antibacterial soap to reduce the bacteria count on the skin. b. apply antibacterial topical medication to the crusted exudate The client should apply topical medication directly to the moist lesion bed. The medication will not penetrate the crusted exudate d. cover affected area with snug fitting clothing The client should use loose-fitting clothes to avoid irritating the lesion

A nurse in a clinic is preparing to obtain a skin specimen from a client who has suspected herpes infection. Which of the following actions should the nurse take? (SATA) a. scrape the site with a wooden tongue depressor b. use a razor to cut the scabbed area to obtain a specimen c. use a cotton-tipped application to obtain fluid from the lesion d. place specimen in a potassium hydroxide (KOH) solution tube e. place specimen tube on ice after obtaining sample

c. use a cotton-tipped application to obtain fluid from the lesion Swab the moist lesion bed under the crust with a sterile cotton tipped applicator to obtain reliable specimen e. place specimen tube on ice after obtaining sample The culturette tube is immediately placed in ice when obtaining a viral specimen a. scrape the site with a wooden tongue depressor a wooden tongue depressor is used to scrape cells of a skin lesion to test for a fungus b. use a razor to cut the scabbed area to obtain a specimen Use a razor to obtain a specimen from a superficial or raised lesion when a shave biopsy is prescribed. d. place specimen in a potassium hydroxide (KOH) solution tube A KOH prep solution is used for distinguishing fungal infections

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? a. "You can can resume playing golf in 2 days." b. "You need to tilt your head back when washing your hair." c. "You can get water in your eyes in 1 day." d. "You need to limit your housekeeping activities."

d. "You need to limit your housekeeping activities." Instruct the pt to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye a. "You can can resume playing golf in 2 days." Don't instruct the pt to resume playing golf for several weeks. This could cause a rise in intraocular pressure or possible injury to the eye b. "You need to tilt your head back when washing your hair." Don't instruct the pt to tilt the head back when washing their hair. This could cause a rise in IOP or possible injury to the eye. c. "You can get water in your eyes in 1 day." The pt shouldn't get water in their eyes for 3-7 days following cataract surgery to reduce the risk for infection and promote healing

A nurse is assessing a pt who sustained a deep partial-thickness and full-thickness burns over 40% of the body 24 hours ago. Which of the following findings are common during this phase? (SATA) A. Temp 36.1 C (97.0 F) B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased HCT

A. Temp 36.1 C (97.0 F) Decreased Temperature can occur in the first few hours following a burn, because the body's ability to regulate temperature is compromised. C. Hyperkalemia Hyperkalemia occurs during the initial phase following a burn as a result of leakage D. Hyponatremia Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. B. Bradycardia Tachycardia occurs during the initial phase following the burn due to sympathetic nervous system compensation E. Decreased HCT HCT increases during the initial phase of a burn due to hemoconcentration

The nurse recognizes which action as the major function of the visual system? A. Differentiate colors. B. Convert light into nerve signals for the brain to interpret. C. Focus light onto the choroid. D. Accommodate vision from light to dark.

B. Convert light into nerve signals for the brain to interpret The major function of the visual system is the conversion of light into nerve signals for interpretation leading to sight. The cones are responsible for color differentiation. The choroid is behind the retina. Accommodation of vision from light to dark is just one aspect of vision.

A nurse is preparing to administer fentanyl to a pt who sustained deep partial-thickness & full thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal

C. Intravenous Use the IV route to administer pain mediation for rapid absorption & fast pain relief during the resuscitation phase a. Subcutaneous don't give subQ injections due to the difficulty of absorption from tissue during the resuscitation phase b. Oral Don't give oral (including buccal, sublingual) meds due to decreased absorption in the GI tract during the resuscitation phase d. Transdermal Don't use the transdermal route of administration due to delays in absorption during the resuscitation phase

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? a. pearly gray tympanic membrane (TM) b. Malleus visible behind the TM c. Presence of soft cerumen in the external canal d. Fluid or bubbles seen behind the TM

D. Fluid or bubbles seen behind the TM Fluid or bubbles seen behind the TM indicates the possibility of otitis media & isn't an expected finding. a. pearly gray tympanic membrane (TM) Pearly gray tympanic membrane (TM) is an expected finding during an otoscopic exam b. Malleus visible behind the TM Visualization of the malleus behind the TM is an expected finding during an otoscopic exam c. Presence of soft cerumen in the external canal Cerumen of various colors, depending on the pt's skin color or ethnic background, is an expected finding in the external ear canal

The nurse prepares the patient for which common diagnostic evaluations during a visit to an eye care provider? A. Pupillary light test, ultrasound of the eye B. Test of peripheral vision, otoscope examination C. Test for presence of bacteria in the conjunctiva, pupillary light test D. Snellen eye chart examination, peripheral vision check

D. Snellen eye chart examination, peripheral vision check The Snellen eye chart and peripheral vision checks are part of the eye exam. The otoscope exam is for assessment of the ear. Bacteria testing in the conjunctiva is not part of a routine exam, but is indicated if there is redness or inflammation of the eye. Ultrasound is not typically conducted unless there are suspected cataracts.

A nurse is completing discharge teaching to a pt following middle ear surgery. Which of the following statements by the pt indicates understanding of the teaching? a. "I should restrict rapid movements & avoid bending from the waist for several weeks." b. "I should wait until the day after surgery to wash my hair." c. "I will remove the dressing behind my ear in 7 days." d. "My hearing should be back to normal right after my surgery."

a. "I should restrict rapid movements & avoid bending from the waist for several weeks." Rapid movements and bending form the waist should be avoided for 3 weeks following ear surgery b. "I should wait until the day after surgery to wash my hair." Avoid showering & washing hair for at least several days up to 1 week following ear surgery c. "I will remove the dressing behind my ear in 7 days." Middle ear surgery is performed through the tympanic membrane, & the pt will have a dry dressing within the ear canal. There is no external excision d. "My hearing should be back to normal right after my surgery." Decreased hearing is expected following middle ear surgery due to presence of a dressing within the ear canal & possible drainage

A nurse is teaching a client who has a history of psoriasis about photo chemotherapy & ultraviolet light (PUVA) treatments. Which of the following instructions should the nurse include in the teaching? a. apply vitamin A cream before each treatment b. Administer a psoralen medication before the tx c. Use this treatment every evening d. Remove the scales gently following each tx

b. Administer a psoralen medication before the tx PUVA tx involved the administration of a medication (psoralen) to enhance photosensitivity a. apply vitamin A cream before each treatment PUVA tx doesn't involve the use of Vitamin A cream c. Use this treatment every evening PUVA tx are completed 2 -3 times/wk and not on consecutive days d. Remove the scales gently following each tx Removal of scales can cause bleeding & isn't recommended when treating psoriasis

A nurse is caring for a patient who has diabetes mellitus & reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a. Cataracts b. Open-Angle Glaucoma c. Macular degeneration d. Angle-closure glaucoma

b. Open-Angle Glaucoma This is a manifestation of open-angle glaucoma. A gradual loss of peripheral vision is a manifestation associated with this diagnosis a. Cataracts A client who has cataracts experiences a decrease in peripheral & central vision due to opacity of the lens c. Macular degeneration A client who has macular degeneration experiences a loss of central vision d. Angle-closure glaucoma A client who has angle-closure glaucoma experiences sudden nausea, severe pain & halos around lights

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? a. presence of a purulent lesion in the external ear canal b. feeling of pressure in the ear c. bulging, red bilateral tympanic membranes d. unilateral hearing loss

d. unilateral hearing loss Unilateral sensorineural hearing loss is an expected finding in Meniere's disease a. presence of a purulent lesion in the external ear canal Meniere's disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding b. feeling of pressure in the ear A feeling of pressure in the ear can occur with otitis media, but is not an expected finding in Meniere's disease c. bulging, red bilateral tympanic membranes Meniere's disease is an inner ear disorder. Bulging, red bilateral tympanic membranes is a finding associated with a middle ear infection

683. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the primary health care provider (PHCP). 4. Accompany the client to the emergency department.

1. Apply ice to the affected eye. Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a PHCP and receive a thorough eye examination to rule out the presence of other eye injuries. Test-Taking Strategy: Focus on the strategic word, immediately. Recalling the principles related to initial treatment of injuries and noting the type of injury sustained will direct you to the correct option.

441. Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication should be applied directly to the wound." 4. "The medication is likely to cause stinging every time it is applied."

4. "The medication is likely to cause stinging every time it is applied." Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling the characteristics of this medication will assist in answering correctly.

349. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided? 1. "Administer the antibiotics until they are gone." 2. "Administer the antibiotics if the child has a fever." 3. "Administer the antibiotics until the child feels better." 4. "Begin to taper the antibiotics after 3 days of a full course."

1. "Administer the antibiotics until they are gone." Rationale: A myringotomy is the insertion of tympanoplasty tubes into the middle ear to promote drainage of purulent middle ear fluid, equalize pressure, and keep the ear aerated. The nurse must instruct parents regarding the administration of antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be completed. Options 2, 3, and 4 are incorrect. Antibiotics are not tapered but are administered for the full course of therapy. Test-Taking Strategy: Focus on the subject, understanding of the instructions about antibiotics. Recall that antibiotics must be taken for the full course, regardless of whether the child is feeling better. This will assist in directing you to the correct option.

143. The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? 1. "I should sleep on my left side." 2. "I should sleep on my right side." 3. "I should sleep with my head flat." 4. "I should not wear my glasses at any time."

1. "I should sleep on my left side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient. Test-Taking Strategy: Focus on the subject, right cataract surgery. Use of the principles of gravity and edema formation will assist in answering this question. Remember to instruct the client to remain off the operative side and to rest with the head elevated to minimize edema formation. This will assist you when answering questions related to cataract surgery.

699. A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? 1. Administer the eye drop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eye drop. 3. Administer the eye drop, wait 15 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 15 minutes, and administer the eye drop.

1. Administer the eye drop first, followed by the eye ointment. Rationale: When an eye drop and an eye ointment are scheduled to be administered at the same time, the eye drop is administered first. The instillation of two medications is separated by 3 to 5 minutes. Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the guidelines for administering eye medications. Eliminate options 3 and 4 first because of the words 15 minutes. Next, thinking about the consistency and absorption of a drop versus ointment will direct you to the correct option.

680. A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2. Tinnitus Rationale: Tinnitus is the most common complaint of clients with otological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. Options 1, 3, and 4 are not associated specifically with problems of the inner ear. Test-Taking Strategy: Note the strategic word, most. Recalling the anatomy and the function of the inner ear will direct you to the correct option.

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? a. increase the intake of deep yellow & orange vegetables b. administer eye drops twice daily c. avoid bending at the waist d. wear an eye patch at night

a. increase the intake of deep yellow & orange vegetables Instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration b. administer eye drops twice daily A client who has primary open-angle glaucoma should administer eye drops twice daily c. avoid bending at the waist A client who is at risk for increased intraocular pressure such a following cataract surgery, should avoid bending at the waist. d. wear an eye patch at night A client who had eye surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury

A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following instructions should the nurse include? (SATA) a. apply an occlusive dressing after application b. apply 3-4 times per day c. wear gloves after application to lesions on the hands d. avoid applying in skin folds e. use medication continuously over a period of several months

a. apply an occlusive dressing after application an occlusive dressing can enhance the efficacy of the topical corticosteroid on the exposed lesions c. wear gloves after application to lesions on the hands Gloves worn after the medication can enhance the efficacy of the topical corticosteroid on the exposed lesions of the hands d. avoid applying in skin folds Corticosteroid cream applied to lesions in skin folds increases the risk of yeast infections b. apply 3-4 times per day Corticosteroid cream is applied 2x daily to prevent development of local & systemic adverse effects e. use medication continuously over a period of several months The client should take periodic medication "vacations" to minimize the risk for development of local & systemic adverse effects

A nurse is reviewing the the health record of a client who has severe otitis media. Which of the following are expected findings? (SATA) a. enlarged adenoids b. report of recent colds c. client prescription for daily furosemide d. light reflexes visible on otoscopic exam in the affected ear e. ear pain relieved by meclizine

a. enlarged adenoids Enlarged tonsils & adenoids are a finding associated with middle ear infection b. report of recent colds Frequent colds are findings associated with a middle ear infection c. client prescription for daily furosemide Furosemide is an ototoxic medication and can cause sensorineural hearing loss, but taking furosemide doesn't cause a middle ear disorder d. light reflexes visible on otoscopic exam in the affected ear Light reflexes are absent or in altered positions in a client who has a middle ear disorder e. ear pain relieved by meclizine Meclizine is prescribed to relieve vertigo for inner ear disorders but doesn't relieve the pain of a middle ear infection