Theory FINAL

A nurse notes during assessment that an older client is exhibiting a number of visual changes. The nurse determines that which assessment findings are associated with normal age-related changes of the eye? Select all that apply. 1. Photophobia 2. Decreased visual acuity 3. Loss of peripheral vision 4. Decreased tolerance of glare 5. Decreased ability to adapt to dark and light

1,2,3,4

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions? Select all that apply. 1. Elevation of the right leg 2. Ambulation in the hall every 4 hours 3. Application of moist heat to the right leg 4. Administration of acetaminophen (Tylenol) 5. Monitoring for signs of pulmonary embolism

1,3,4,5 Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.

A client has sustained significant eye damage as a result of glaucoma and has impaired vision. The nurse interprets that the client demonstrates a need for further instruction in adapting to this impairment if the client makes which statement? 1. "I won't have difficulty seeing if I drive at night." 2. "Night lights have been placed in the hallways at home." 3. "It's important for me to have periodic eye examinations." 4. "My family will drive me to my eye doctor's office when eye examinations are needed."

1.

A client is diagnosed with glaucoma. Which nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections

1.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding.

1. Hold the feeding. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

A chronic obstructive pulmonary disease (COPD) patient experiences chronic shortness of breath and difficulty expiring air. Which of the following exercises is best for COPD patients to promote effective expulsion of trapped air from the lungs? a. Inspiratory muscle training b. Paced walking c. Pursed-lip breathing d. Diaphragmatic breathing

c. Pursed-lip breathing

Which action by the nurse is consistent with culturally competent care? A. Treating each client the same regardless of race or religion B. Ensuring that all Native American clients have access to a shaman C. Understanding one's own world view in addition to the client's D. Including the family in the plan of care for older clients

c. The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views (C). Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity (A, B, and D).

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV

c. The statement above describes a stage III ulcer which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle (C). A stage I ulcer includes intact skin with nonblanchable redness of a localized area (A). A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed (B). Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer (D).

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

d

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for side/adverse effects to the medication. Which finding indicates that the client is experiencing an adverse effect?

1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

A client returns to the ambulatory care unit 1 day after cataract removal surgery for follow-up care. The nurse checks the client's cornea with a flashlight, expecting which finding? 1. Clear 2. Cloudy 3. Spotted 4. Sanguineous

1. After cataract surgery, the cornea should be clear, round, and smooth. A cloudy or spotty appearance or a scattering of the light could indicate the presence of infection or increased intraocular pressure. The term sanguineous denotes blood; there should be no bleeding in the corneal area postoperatively.

Cyclobenzaprine hydrochloride (Flexeril) is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus

1. Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? 1. Hold the feeding. 2. Reinstill the amount and continue with administering the feeding. 3. Elevate the client's head at least 45 degrees and administer the feeding. 4. Discard the residual amount and proceed with administering the feeding.

1. Hold the feeding Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. 1. Dyspnea at rest 2. Clubbed fingers 3. Muscle retractions 4. Decreased respiratory rate 5. Increased body temperature 6. Prolonged expiratory breathing phase

1., 2., 3., 6. The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection.

The nurse is preparing a teaching plan for a client who is undergoing 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. Place an eye shield on the surgical eye at bedtime. 4. Episodes of sudden severe pain in the eye are expected. 5. Contact the surgeon if a decrease in visual acuity occurs. 6. Take acetaminophen (Tylenol) for minor eye discomfort.

1., 2., 5., 6. 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. 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 intraocular pressure, such as bending over.

After a transurethral prostatectomy a patient returns to his room with a triple lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output?

1320 mL Rationale: 150mL x 8 hours = 1200mLs 1200mLs-2520mLs= 1320 mL

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. 1. Increased appetite 2. Loss of consciousness 3. Loss of bowel control 4. Loss of bladder control 5. Decreased blood pressure 6. Decreased tactile sensation

2-6

In planning nursing care for an 85 year old male, the most important basic need that must be met it? 1. Assurance of sexual intimacy 2. Preservation of self-esteem 3. Expanded socialization 4. Increase in monthly income

2.

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. Side-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.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the test results documented in the client's chart, knowing that which is the range for normal intraocular pressure? 1. 2 to 7 mm Hg 2. 10 to 21 mm Hg 3. 22 to 30 mm Hg 4. 31 to 35 mm Hg

2.

The nurse is assigned to care for a client in traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? 1. Ensure that the knots are at the pulleys. 2. Check the weights to ensure that they are off of the floor. 3. Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4. Monitor the weights to ensure that they are resting on a firm surface.

2. Check the weights to ensure that they are off of the floor.

A nurse is caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which client problem should be the priority? 1. Risk for dehydration caused by bleeding in the gastrointestinal tract 2. Risk for choking and aspiration related to a poor gag reflex post-procedure 3. Lack of knowledge of post-procedure care related to not having had an EGD before 4. Sore throat related to passage of the endoscope through the pharyngeal region during EGD

2. Risk for choking and aspiration related to a poor gag reflex post-procedure EGD is a visual inspection of the esophagus, stomach, and duodenum using a fiberoptic endoscope. All the client problems listed as options are potentially appropriate for a client who just had an EGD. After the procedure, the client is recovering from the use of conscious sedation and the administration of a local anesthetic to the throat. Therefore, the client problem in option 2 is most important at this point because of the potential for airway problems.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. 1. Hypocapnia 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyperinflated chest noted on the chest x-ray 3. Decreased O2 saturation with mild exercise

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 not sleep on my left side." 2. "I should not sleep on my right side." 3. "I should not sleep with my head elevated." 4. "I should not wear my glasses at any time."

2. 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.

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? 1. Pain 2. Anxiety 3. Depression 4. Withdrawal

2. Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptom.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which best describes Cheyne-Stokes respirations? 1. Continuous rapid regular breathing 2. Periods of apnea followed by bradypnea 3. Periods of apnea followed by deep rapid breathing 4. Periods of bradypnea followed by periods of tachypnea

2. Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. Therefore options 1, 2, and 4 are incorrect.

In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse understands that which characterizes the medication action? 1. Produces miosis of the operative eye 2. Dilates the pupil of the operative eye 3. Constricts the pupil of the operative eye 4. Provides lubrication to the operative eye

2. 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.

A nurse is caring for a 78 year old math with diarrhea. Of the following problems, which is the most important to consider? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

2. DHD

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 to 4 L/min. The nurse responds that this would be harmful because a higher oxygen flow rate could lead to which physical responses? 1. Drying of nasal passages 2. Decrease in the client's oxygen-based respiratory drive 3. Increase for the risk of pneumonia from drier air passages 4. Decrease in the client's carbon dioxide-based respiratory drive

2. Normally respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural regulator becomes ineffective owing to exposure to high carbon dioxide levels for prolonged periods. Thus, the level of oxygen provides the respiratory stimulus for these clients. The client with COPD should be instructed not to increase the oxygen flow rate level independently because a higher oxygen level could obliterate the respiratory drive, leading to respiratory failure. Options 1, 3, and 4 are not physical responses that would occur.

Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol (Betoptic) 2. Atropine sulfate (Isopto Atropine) 3. Pilocarpine hydrochloride (Isopto Carpine) 4. Pilocarpine (Ocusert Pilo-20, Ocusert Pilo-40)

2. Options 1, 3, and 4 are miotic agents used to treat glaucoma. The correct option 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.

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma? 1. Client report of blurred vision 2. Client report of "tunnel vision" 3. Client report of ocular erythema 4. Client report of halos around lights

2. POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.

A client has been taking omeprazole (Prilosec) for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation

2. PPI

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? 1. Tests the corneal reflexes 2. Tests the six cardinal positions of gaze 3. Tests visual acuity, using a Snellen eye chart 4. Tests sensory function by asking the client to close eyes and then lightly touching the forehead, cheeks, and chin

2. Rationale: Testing the six cardinal positions of gaze is done to assess for muscle weakness in the eyes. The client is asked to hold the head steady, and then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. A Snellen eye chart assesses visual acuity and cranial nerve II (optic). Testing sensory function by having the client close his or her eyes and then lightly touching areas of the face and testing the corneal reflexes assess cranial nerve V (trigeminal).

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2. Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

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

2. Tinnitus is the most common complaint of clients with otological disorders, especially disorders 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 disorders of the inner ear.

A client's nasogastric (NG) feeding tube has become clogged. The nurse should take which action first? 1. Replace the tube. 2. Aspirate the tube. 3. Flush with carbonated liquids. 4. Flush the tube with warm water.

2. aspirate the tube The first step in attempting to unclog a feeding tube is gently aspirating the tube. If this is not successful, flushing the tube with warm water can be tried. Carbonated liquids sometimes are used for flushing a clogged tube (depending on agency policy and procedures), but the tube must be rinsed thoroughly afterward to avoid stickiness. Replacement of the tube is the last step if other actions are unsuccessful. Also, the health care provider may prescribe another method of alleviating the obstruction.

The nurse suggests that a patient recieve a palliative care consultation for symptom management related to anxiety and increassing pain. A family member asks the nurse if this means that the patient is dying and is now in "hospice" What does the nurse tell the family member about palliative care? SATA 1. Hospice and palliative care are the same thing 2. Palliative care is for any patient, any time, any disease, any setting 3. Palliative care strategies are primarily designed to treat the illness 4. Palliative care interventions relieve the symptoms of illness and treatment

2., 4.

The nurse is preparing to care for a dying client, and several family members are at the bedside. Which therapeutic techniques should the nurse use when communicating with family? SATA a. Discourage reminiscing b. Make the decisions for the family c. Encourage expression of feelings, concerns and fears d. Explain everything that is happening to all family members e. Touch and hold the clients family's hands if appropriate d. Be honest and let the client and family know that they will not be abandoned by the nurse.

3, 5, 6 The nurse must determine whether there is a spokesperson in the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist only when asked.

The nurse is caring for a client who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

3.

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.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block

3.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1. Ad lib activities as tolerated 2. Strict bed rest for 24 hours after transfer 3. Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet

3. Bathroom privileges and self-care activities On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that this type of hearing loss is caused by which problem? 1. A defect in the cochlea 2. A defect in the 8th cranial nerve 3. A physical obstruction to the transmission of sound waves 4. A defect in the sensory fibers that lead to the cerebral cortex

3. A conductive hearing loss occurs as a result of a physical obstruction to the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations

3. Cimetidine is a histamine (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

The nurse is caring for a client who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

3. Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle

3. Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more chronic.

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. 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.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.

3. Place a clock and calendar in the clients room An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

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. 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 his or her life. Options 1, 2, and 4 are not accurate instructions.

A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies? 1. Administration of plasma expanders, low-flow oxygen, and suctioning 2. Administration of bronchodilators, intubation, and mechanical ventilation 3. Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure 4. Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask

3., Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema. Options 1, 2, and 4 are incorrect.

A client reports to the health care clinic for an eye examination, and a diagnosis of macular degeneration is made. Which nursing assessment question will most specifically elicit information regarding the clinical manifestations associated with this disorder? 1. "Do bright lights bother you?" 2. "Do you have any pain in your eye?" 3. "Have you had any blurred vision?" 4. "Are you having difficulty seeing things out of the sides of your eyes?"

3.Blurred central vision occurs with macular degeneration. Glare from bright lights is a common complaint in the client with a cataract. Pain in the eye is not specifically associated with macular degeneration. Changes in peripheral visual acuity most often occur with glaucoma.

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status changes

3.Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.

A client with retinal detachment is admitted to the nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the client's affected eye

4.

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? 1. It reduces the secretions in the bronchi. 2. It causes dilation of the bronchial smooth muscles. 3. It relieves pain, which helps to reduce the dyspnea. 4. It helps to reduce anxiety and oxygen consumption.

4.

When caring for an 87 year old patient, the nurse needs to understand that which of the following most directly influences the patients current self concept? 1. Attitudes and behaviors of relatives providing care 2. Caring behaviors of the nurse and health care team 3. Level of education, economic status, and living conditions 4. Adjustment to role change, loss of loved ones, and physical energy

4.

A client with retinal detachment is admitted to the nursing unit in preparation for a scleral buckling procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Elevating the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the client's affected eye

4. Placing an eye patch over the client's affected eye

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

4. 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.

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum 2. The serum potassium level changes from 3.8 to 3.1 mEq/L 3. B-natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL 4. Urine output increases from 10 mL/hour to greater than 50 mL hourly

4. Bumetanide is a diuretic and expected outcomes include increased urine output, decreased crackles, and decreased weight. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do-not-resuscitate (DNR) order. What is the nurse's priority action? 1. Prepare the client for intubation and mechanical ventilation. 2. Talk to the family about the client's right to change his mind. 3. Administer an anti-anxiety medication to the client to ease his breathing. 4. Notify the health care provider that the client is rescinding the DNR order.

4. COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the health care provider to reverse the DNR prescription on the chart. The health care provider also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the health care provider. Option 2 is incorrect because the health care provider should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

4. Chest pain that occurs suddenly The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red bloody urine 2. Pain related to bladder spasms 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 90/50 mm Hg; pulse, 130 beats/minute

4. Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The HCP should be notified.

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4. In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

4. 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. Options 1, 2, and 3 are incorrect.

The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promotes carbon dioxide elimination Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for follow-up care

A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A. The client reports a continuous feeling of needing to void. B. Urinary drainage is pink 24 hours after surgery. C. The hemoglobin level is 8.4 g/dL 3 days postoperatively. D. Sterile saline is being used for bladder irrigation.

A. The client reports a continuous feeling of needing to void. B. Urinary drainage is pink 24 hours after surgery. C. The hemoglobin level is 8.4 g/dL 3 days postoperatively. D. Sterile saline is being used for bladder irrigation.

In assessing an older client with dementia for sundowning syndrome, what assessment technique is best for the nurse to use? A. Observe for tiredness at the end of the day. B. Perform a neurologic exam and mental status exam. C. Monitor for medication side effects. D. Assess for decreased gross motor movement.

A. Sundowning syndrome is a pattern of agitated behavior in the evening, believed to be associated with tiredness at the end of the day combined with fewer orienting stimuli, such as activities and interactions. (B, C, & D) with not provide information about this syndrome.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler's position without a pillow behind the head B. Semi-Fowler's position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table

Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a client on the right side with the head of the bed elevated (C) does not facilitate lung expansion.

Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A. Auscultation of vesicular breath sounds B. Pulse oximetry reading of 89% C. Arterial Pao2 of 86% D. Resonance on percussion of the lungs

B. Pulse oximetry reading of 89% indicates hypoxia, a, c, and d are all normal assessment findings

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A. Draw arterial blood gases. B. Notify the primary health care provider. C. Position in a high Fowler's position with the legs down. D. Obtain a chest X-ray.

C. Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

Common meds for GERD what class? Cimetadine (tagamet) Zantac Famotadine Reglan "zoles" prilosec

Cimetadine (tagamet), Zantac, and Famotadine are all examples of H2 receptor blockers. Reglan is a prokinetic agent and Zoles and prilosec are PPI

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? 1. Provide a dark room. 2. Provide a well-lighted room. 3. Reorient the client every 8 hours only. 4. Withhold benzodiazepines and sedatives.

Delirium may occur during the last days of life. Nursing management of a terminally ill client experiencing delirium includes providing a room that is quiet, well lighted, and familiar to reduce the effects of delirium; reorienting the dying client to client, place, and time with each encounter; and administering prescribed benzodiazepines and sedatives as needed.

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?"

Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? A. Stand on a line drawn 10 feet from the chart. B. Read each sentence slowly and carefully. C. Cover one eye while reading the chart with the other. D. Begin by identifying the first line that is hard to read.

Rationale: Each eye should be tested separately (C) because visual acuity can vary from one eye to the other. A Snellen chart scores vision in comparison with what a person with normal vision can read at a distance of 20 feet (A). The Snellen chart is comprised of letters, not sentences (B). The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read (D).

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1. Sitting position 2. Tripod position 3. Supine position 4. High Fowler's position

The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high-Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size.

With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.

An older adult client reports recurring calf pain after walking 1 to 2 blocks at the local mall. He tells the nurse that the pain disappears after sitting down. The nurse notes that the skin on his feet is shiny and cool. Which of the following nursing interventions is most appropriate at this time? A. Position the leg dependently. B. Elevate the leg above the heart. C. Immobilize the leg to prevent further injury. D. Assess dorsiflexion and extension of the foot.

a.

Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

a.

For the same patient what type of surgery would you expect to have? a. Iridotomy b. Scleral buckling c. Cryopexy d. Trebeculectomy

a. Iridotomy is usually the surgery of choice for acute angle closure glaucoma. Scleral buckling and Cryopexy are seen with Retinal Detachment and a Trebeculectomy would be used for open-angle glaucoma to reduce to IOP

Which physical assessment should the nurse perform to assist in the diagnosis of DVT? a. Measure calf circumference bilaterally b. Observe for excessive bruising c. Perform test for a positive Homan's sign d. Auscultate for bruits

a. Measure calf circumference bilaterally This provides a baseline for further comparison. A positive Homan's sign is only present in about 10% of cases.

Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

a. Reduced renal excretion During the aging process, reduced renal function (A) is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not (C), predisposes an older adult to an increase in adverse drug reactions. (B) may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders (D) is not increased nor does it affect drug pharmacotherapeutics.

If a client has been treated for a pneumonia infection, what is the best indicator that their inection has improved or been treated? a. Sputum culture is negative b. Ampicillin peak and trough levels are in the therapeutic range c. O2 sat is 92% d. temperature went from 102F back down to 98.6F

a. Sputum cultures are negative

The nurse is performing an assesment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? a. crusting b. wrinkling c. deepening of expression lines d. thinning and loss of elasticity of the skin

a. crusting

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A. Help the client dangle his legs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times a day.

a. help the client dangle his legs The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on the list? SATA a. coffee b. chocolate c. peppermint d. nonfat milk e. fried chicken 6. scrambled eggs

a., b., c., e

An older adult client has been on bed rest for 10 days. The nurse recognizes that which of the following may represent a physical finding related to this client's immobility? A. Gingival sensitivity B. Abdominal distention C. Long-term memory loss D. Decreased urine output

b.

On an ECG monitor strip, the nurse expect to not which assesssment finding indicating atrial fibrillation? a. Widened QRS complex b. Absence of a P wave c. Absence of ST segment d. Elecation of ST segment

b. Absence of a P wave

A patient came into the emergency department with complaints of extreme eye pain. On examination you notice pupils are non-reactive to light and the patient states they have blurred vision and are seeing halos. You suspect what type of opthalmic emergency? a. Retinal detachment b. Angle-Closure glaucoma c. Open-angle glaucoma d. vitreaous detachment

b. Angle-Closure glaucoma is characterized by blurred vision, halos , pupils that are non-reactive to light and severe pain.

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A. Administer epinephrine. B. Defibrillate immediately. C. Bolus with isotonic fluid. D. Notify the health care provider.

b. Defibrillation is the first and most effective emergency treatment for ventricular fibrillation (B). The others may follow the first action (A, C, and D).

The home health nurse is visiting a client for the first time. While assessing the client's medication hx, is is noted that there are 19 medications and several OTC medications. Which intervention should the nurse take first? a. Check for medication interactions b. Determine whether there are medication duplications c. Call the prescribing HCP and report polypharmacy d. Determine whether a family member supervises medication administration

b. Determine whether there are medication duplications

The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees

b. Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).

A legal document that specifically designates someone to make decisions regarding medical and end-of-life care if a patient is mentally incompetent is a(n): a. Do-not-resuscitate order b. Durable power of attorney c. Advance directive d. General power of attorney

b. durable power of attorney

The long-term nurse is performing assessments on several of the residents. Which are the normal A-R changes the nurse expects to note? (SATA) a. Increased HR b. Decline in visual acuity c. Decreased Respiratory rate d. Decline in LT memory e. Increased susceptibility to urinary tract infection f. Increased incidence of awakening after sleep onset

b., e., f. Anatomical changes to the eye effect the individuals vision, light adaptations and visual fields are reduced. Although lung function decreases, the respiratory rate is usually 12-24, heart rate decreases and the valves thicken. A-R changes that effect the urinary tract increase an older client's susceptibility to urinary tract infections. Short term memory declines with age, but LT memory usually is maintained. Change in sleep patterns is a consistent, a-r change. Older persons experience an increased incidence of awakening after sleep onset.

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print

c

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?"

d.

Which diagnostic is used to measure pressure within the right atrium? a. Chest X-ray b. Echocardiogram c. Electrocardiogram d. Pulmonary artery catheterization

d.

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A. "I will not take my digoxin if my heart rate is higher than 100 beats/min." B. "I should weigh myself once a week and report any increases." C. "It is important to increase my fluid intake whenever possible." D. "I should report an increase of swelling in my feet or ankles."

d. An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C).

The nurse is providing instructions to an older adult client who is taking digoxin. The nurse notes that which age related body change could place the client at risk for digoxin toxicity? a. decreased muscle strength and loss of bone density b. decreases cough efficiency and decreased vital capacity c. decreased salivation and decreased gastrointestinal motility d. decreased lean body mass and decreased glomelular filtration rate.

d. decreased lean body mass and decreased GFR The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased GFR.

Which assessment finding would indicate that a patient is having right sided heart failure? a. dyspnea b. fatigue c. tachycardia d. edema

d. edema

When assessing safety for the older adult, which of the following is of highest priority to the nurse? A. The client has a cataract in the right eye. B. The client is not married and lives alone. C. The client lives in a two-story building. D. The client reports a history of repeated falls.

d.Risk assessment for falls is critical element in caring for the adult. ABC are importnat components in assessing client risk, but a hisotory of prior falls puts the older client at a very high risk for falling again