NUR 229 Exam 3 ATI Questions

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? "I will inhale slowly through pursed lips to help me breathe better." "I will avoid getting a flu shot." "I will follow a daily diet high in calories and protein." "I will lie on my stomach to practice abdominal breathing every day."

"I will follow a daily diet high in calories and protein." Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) Dyspnea Bradycardia Barrel chest Clubbing of the fingers Deep respirations

-Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. -Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. -Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back. -Bradycardia is incorrect. With emphysema, the heart rate will increase as the heart tries to compensate for less oxygen to the tissues. -Deep respirations is incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; consequently, respirations become increasingly shallow.

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.) Rifampin Isoniazid Acyclovir Pyrazinamide Montelukast

-Rifampin is correct. A client who has tuberculosis should take rifampin to kill slower growing micro-organisms. The nurse should instruct the client to avoid drinking alcohol, to expect body secretions to have a reddish-orange tinge, and to report a yellow tinge to the skin or whites of the eyes. -Isoniazid is correct. A client who has tuberculosis should take isoniazid to kill actively growing mycobacteria. The nurse should instruct the client to take the medication on an empty stomach and to take a daily multiple vitamin. -Pyrazinamide is correct. A client who has tuberculosis usually takes pyrazinamide for the first 12 months of therapy and can shorten the entire course of therapy to 6 months. The nurse should instruct the client to drink at least 240 mL (8 oz) of fluid when taking the medication and to protect himself from the sun with cotton clothing and sunscreen. -Acyclovir is incorrect. A client should take acyclovir treat a viral infection, such as herpes simplex virus and herpes zoster. -Montelukast is incorrect. A client should take montelukast to manage chronic asthma, seasonal allergic rhinitis, or for prophylaxis of bronchospasms.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? A. "Without treatment, glaucoma can cause blindness." B. "Double vision is a common symptom of glaucoma." C. "Glaucoma is caused by inadequate production of fluid within the eye." D. "Use of eye drops will improve vision over time."

A. "Without treatment, glaucoma can cause blindness." The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? A. "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and warfarin work together to dissolve the clots." D. "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

A. 'Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and IN are within therapeutic range, the heparin can be discontinued.

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments? A. Cataracts B. Macular degeneration C. Diabetic retinopathy D. Glaucoma

A. Cataracts Cataracts are clouding of the lens of the eye which can cause blurred, hazy vision.

A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include? A. Decrease in body fat B. Increase in gag reflex C. Increase in muscle mass D. Decrease in systolic blood pressure

A. Decrease in body fat Older adult clients experience a decrease in body fat and tissue elasticity.

A nurse is teaching a newly licensed nurse about physiological changes in the digestive system that occur with aging. The nurse should include older adults might experience which of the following physiological changes? A. Decreased intestinal peristalsis B. Decreased pH of the stomach C. Increased gastric acid production D. Increased muscle tone of the bowel

A. Decreased intestinal peristalsis Decreased intestinal peristalsis can cause constipation in older adult clients.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching? A. Exercise at least three times per week. B. Take diuretics early in the morning and before bedtime. C. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. D. Take naproxen for generalized discomfort.

A. Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? A. Frothy sputum B. Dependent edema C. Nocturnal polyuria D. Jugular distention

A. Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is assessing an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect? A. Increased calcification of bones B. Increased balance C. Increased muscle mass D. Increased joint stiffness

D. Increased joint stiffness Increased joint stiffness is an expected age-related change for an older adult client. This can cause decreased joint mobility and strength and increase the client's risk for falls.

A resident of a LTC facility has moderate hearing loss. When communicating with this resident, what should the nurse do? A. Repeat each direction or question in different terms in order to maximize understanding. B. Use vocabulary and concepts that are as simple and unambiguous as possible. C. Use written communication whenever possible in order to minimize the client's frustration. D. Minimize background noises and ensure that lighting is adequate to see the nurse's face.

D. Minimize background noises and ensure that lighting is adequate to see the nurse's face. When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading.

A nurse is caring for an older adult client who experienced temporary disorientation following surgery. The nurse should identify that this finding as a manifestation of which of the following complications? A. Postoperative cognitive dysfunction B. Alzheimer's disease C. Dementia D. Postoperative delirium

D. Postoperative delirium Postoperative delirium is a temporary condition in which clients become disoriented and confused following anesthesia. This condition can last up to a few weeks.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? A.Furosemide B. Hydrochlorothiazide C. Metolazone D. spironolactone

D. spironolactone Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia.

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? A. Dependent rubor B. Edema C. Hair loss D. Thick, deformed toenails

Edema An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VT). The nurse should instruct the client to avoid which of the following unsafe actions? A. Elevating her feet B. Massaging her legs C. Flexing her ankles D. Ambulating soon after surgery

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? Crackles Rhonchi Stridor Wheezes

Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching? A. "I may eat 10 ounces of lean protein each day." B. "Fresh fruits make a good snack option." C. "I will replace table salt with dried herbs." D. "I may thicken gravies with cornstarch as I cook."

A. "I may eat 10 ounces of lean protein each day." Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? A. Impaired tissue perfusion B. Alteration in body image C. Alteration in activity tolerance D. Impaired skin integrity

A. Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention.

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? A. Lethargy B. High-grade fever C. Weight gain D. Dry cough

A. Lethargy Manifestations of pulmonary tuberculosis include lethargy and fatigue.

A nurse is teaching a client about medications for glaucoma. What is the main marker of glaucoma control with medication? A. Lowering intraocular pressure to target pressure B. Reducing the appearance of optic nerve head C. Changing the opacity of the lens D. Increasing the visual field

A. Lowering intraocular pressure to target pressure The main marker of the efficacy of the medication in glaucoma control is lowering of the intraocular pressure to the target pressure.

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments? A. Macular degeneration B. Diabetic retinopathy C. Glaucoma D. Cataracts

A. Macular degeneration Manifestations of macular degeneration include loss of central vision. It is caused by degeneration of the macula, a small central portion of the retina, and can lead to blindness.

The older adult client, who lives alone, has been admitted to the ICU following a stroke. She is now agitated and complaining about the noise. What will the nurse add to the client's care plan. A. Provide a consistent, predictable pattern of stimulation B. Provide pet therapy. C. Offer frequent back rubs. D. Instruct the client in self-simulation methods such as singing.

A. Provide a consistent, predictable pattern of stimulation In some clients, especially those coming from a quiet environment with unvarying stimuli, the experience of being hospitalized quickly results in sensory overload. One nursing action to decrease excessive stimulation is to provide a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment.

A nurse is caring for a client who is at risk for sensory overload. Which of the following actions should the nurse take? A. Provide the client with a blindfold. B. Keep the door to the client's room open. C. Wear hard-soled shoes. D. Spread client care activities throughout the shift.

A. Provide the client with a blindfold A blindfold and ear plugs can reduce sensory overload by blocking light and noise.

The nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the nurse include? Select all that apply. A. Sleeplessness B. Increased interest in interactions with others C. Decreased interest in activities D. Increased appetite E. Depression

A. Sleeplessness C. Decreased interest in activities E. Depression Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The client who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as depression mounts, leading to further sensory deprivation.

A nurse in a long-term care facility is caring for a client who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first? A. Take the client for a walk outdoors and ask them to talk about their family. B. Administer alprazolam to the client to decrease their anxiety. C. Take the client to their room so they will not upset other clients. D. Administer haloperidol to the client to decrease their agitation.

A. Take the client for a walk outdoors and ask them to talk about their family. Using the least restrictive/least invasive priority framework, the nurse caring for a client who has dementia should attempt the least restrictive action first. Taking the client outdoors for a walk provides a distraction and asking them to talk about their family is a form of reminiscence therapy that can be calming for the client.

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? Administer a short-acting ß2 -agonist (SABA). Obtain a peak flow reading. Administer an inhaled glucocorticoid. Determine the cause of the acute exacerbation.

Administer a short-acting B2 -agonist (SABA). When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.

A nurse is teaching a client who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the client to use to abort an acute asthma attack? Beclomethasone Salmeterol Formoterol Albuterol

Albuterol Albuterol is an inhaled short-acting beta, agonist (beta,-adrenergic agonist) used as a rescue medication to relieve an acute asthma attack. Albuterol dilates the airways, decreases wheezing, and improves oxygenation.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn via metered-dose inhaler B. Montelukast orally C. Budesonide via dry-powder inhaler D. Albuterol via jet nebulizer

Albuterol via jet nebulizer The nurse should identify that albuterol is a bronchodilator used as the first medication of choice to stop bronchospasm or constriction in clients who have acute asthma exacerbation.

A nurse is assisting an older client who is sedentary plan a new exercise regiment. Which of the following activities should the nurse recommend? A. Tennis B. Walking C. Running D. Jumping rope

B. Walking The nurse should recommend low impact exercises, such as yoga or walking, to maintain and increase strength and flexibility.

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A. "Reaching your goal blood pressure will occur within 2 months." B. "Diuretics are the first type of medication to control hypertension." C. "Limit your alcohol consumption to three drinks a day." D. "Plan to lower saturated fats to 10 percent of your daily calorie intake."

B. "Diuretics are the first type of medication to control hypertension." The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure.

A nurse is teaching a client who has chronic obstructive pulmonary disease and is to start using fluticasone by MDI twice daily. Which of the following instructions should the nurse include? A. "Check your heart rate before each dose." B. "Inspect your mouth for lesions daily." C. "Use this medication to relieve an acute attack." D. "Skip the morning dose if you do not have any symptoms."

B. "Inspect your mouth for lesions daily." The nurse should instruct the client to inspect her mouth daily. Fluticasone is a corticosteroid, which reduces the client's immunity and increases the risk for infection, such as Candida albicans.

Using the least restrictive/least invasive priority framework, the nurse caring for a client who has dementia should attempt the least restrictive action first. Taking the client outdoors for a walk provides a distraction and asking them to talk about their family is a form of reminiscence therapy that can be calming for the client. A. "Dementia is characterized by a sudden onset of confusion." B. "An altered level of consciousness is associated with dementia." C. "The signs of dementia are progressive and irreversible." D. "Dementia can be triggered by a high fever or dehydration."

B. "The signs of dementia are progressive and irreversible." Dementia is a progressive disorder that is irreversible.

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include? A. "Apply ice packs to your legs." B. "Use elastic stockings." C. "Remain on bed rest." D. "Place your legs in a dependent position while in bed."

B. "Use elastic stockings." Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates on of the clients is experiencing delirium. A. A client wants to know the current time while there is a clock on the wall. B. A client attempts to climb out of bed and repeatedly states she must get home. C. A client requests extra blankets when the thermostat in the room indicates 25.6° C (78° F). D. A client refuses to get out of bed and has no motivation to attend to daily hygiene.

B. A client attempts to climb out of bed and repeatedly states she must get home. Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching? A. Apply a heating pad on a low setting to help relieve leg pain. B. Adjust the thermostat so that the environment is warm. C. Wear antiembolic stockings during the day. D. Rest with the legs above heart level.

B. Adjust the thermostat so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

A nurse is teaching a client about diagnostic vision tests. The nurse should include that which of the following tests is performed to diagnose macular degeneration? A. Refraction test B. Amsler grid C. Intraocular pressure D. Snellen chart

B. Amsler grid An Amsler grid test uses a grid to check for impaired central vision and diagnose macular degeneration.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. Increase the oxygen flow to 3 L/min. B. Assess the client's respiratory status. C. Call emergency services for the client. D. Have the client cough and expectorate secretions.

B. Assess the client's respiratory status. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. C. Bend at the waist to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids.

B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery.

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? A. Sodium 136 mEq/L B. Potassium 2.3 mEq/L C. Chloride 99 mEq/L D. Calcium 10 mg/dL

B. Potassium 2.3 mEg/L A serum potassium below 3 mEq/L is a critical laboratory value. The nurse should report this finding to the provider immediately and monitor the client for dysrhythmias.

A nurse is teaching an older adult client about a new medication. Which of the following actions should the nurse take? A. Avoid repeating information to the client. B. Present the information in small segments. C. Dim the lights in the client's room. D. Provide reading material using blue-colored ink.

B. Present the information in small segments The nurse should provide short educational sessions, with regular breaks, to promote learning.

A nurse is teaching a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change? A. Increased tone of eye muscles. B. Reduced depth perception. C. Reduced thickness of the natural lens. D. Increased flexibility of the lens.

B. Reduced depth perception A decrease in depth perception is an expected age-related change in older adult clients. This change can result in an increased risk of tripping and falling.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will list foods that are high in calcium, which should be avoided. B. The client will walk for 30 min 5 days a week. C. The client will increase calorie intake by 200 cal per day. D. The client will replace cigarettes with smokeless tobacco products.

B. The client will walk for 30 min 5 days a week. CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. Recommend that the partner place the client in a long-term care facility. B. Suggest that the partner see a counselor to help him cope with his exhaustion. C. Ask the partner to talk about his difficulties in caring for the client. D. Tell the partner to call a family meeting to get help.

C. Ask the partner to talk about his difficulties in caring for the client. The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: A. a recent driving accident while changing lanes. B. frequent episodes of double vision. C. Light flashes and floaters in front of the eye. D. headaches, nausea, and redness of the eyes.

C. Light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Reposition the client every 3 hr. B. Massage bony prominences to promote circulation. C. Provide the client with a diet high in protein. D. Apply cornstarch to keep the skin dry.

C. Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? A. Remind the client to tell the nurse when he has to urinate. B. Use adult diapers to prevent frequent clothing changes. C. Take the client to the bathroom every 2 hr. D. Request a prescription for an indwelling urinary catheter.

C. Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching? A. "Take cromolyn sodium at the first sign of breathing difficulty." B. "You should stop playing basketball, but you can swim instead." C. "Use the peak expiratory flow meter once per week." D. "Avoid triggers that cause an attack."

D. "Avoid triggers that cause an attack." The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? A. "Bloodshot eyes on the day of surgery should be reported to the provider." B. "Warm compresses should be applied to the eye three times daily." C. "Photophobia is expected for 2 to 3 days." D. "Vision will be greatly improved on the day of surgery."

D. "Vision will be greatly improved on the day of surgery." Vision should be greatly improved on the day of surgery. This information should be included in the teaching.

The nurse should recognize the greatest risk for the development of blindness in which of the following clients? A. A 30 y/o man with astigmatism B. A 58 y/o woman with hyperopia C. A 28 y/o man with myopia D. A 58 y/o woman with macular degeneration

D. A 58 y/o woman with macular degeneration The most common causes of blindness and visual impairment among adults 40 years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts. The 58-year-old woman with macular degeneration has the greatest risk for the development of blindness related to her age and the presence of macular degeneration.

A nurse is reviewing the medical records of several clients who have had their intraocular pressure (IOP) measured. Which client would the nurse identify as having increased IP suggesting glaucoma? A. Client with IOP 15 mm Hg B. Client with IOP 12 mm Hg C. Client with IOP 21 mm Hg D. Client with IOP 24 mm Hg

D. Client with IOP 24 mm Hg When IOP is in balance, the pressure ranges from 10 to 21 mm Hg. Increased IOP greater than 21 mm Hg suggests glaucoma.

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging? A. Increase in percentage of body water. B. Decrease in systolic blood pressure. C. Increase in saliva production. D. Decrease in kidney function.

D. Decrease in kidney function Older adult clients can experience a decrease in kidney function which can result in an extracellular fluid volume deficit and dehydration.

A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include? A. Decreased thickness of tympanic membranes B. Decreased ear wax C. Decreased tinnitus D. Decreased ability to hear high-frequency sounds

D. Decreased ability to hear high-frequency sounds Older adult clients might experience a loss of acuity to high-frequency sound.

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment? A. Removing all furnishings to eliminate any obstruction. B. Keeping the house dimly lit at all times to avoid sensory overload. C. The client should be admitted to the hospital after this surgery. D. Having a caregiver in the home for the first few days after surgery.

D. Having a caregiver in the home for the first few days after surgery. The nurse should encourage enlisting the help and cooperation of family and friends, education, assembling sensory aids and equipment, contacting home health services, and locating additional support groups as needed.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? Restrict the client's fluid intake to less than 2 L/day. Provide the client with a low-protein diet. Have the client use the early-morning hours for exercise and activity. Instruct the client to use pursed-lip breathing.

Instruct the client to use pursed-lip breathing. Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply) Night sweats Low-grade fever Weight gain Flushed cheeks Blood in the sputum

Night sweats is correct. Night sweats are a manifestation of tuberculosis. Low-grade fever is correct. Low-grade fever is a manifestation of tuberculosis. Blood in the sputum is correct. Blood-streaked sputum is a manifestation of tuberculosis. Weight gain is incorrect. Weight loss, not weight gain, is a manifestation of tuberculosis. Flushed cheeks is incorrect. Flushed cheeks are a manifestation of pneumonia, not tuberculosis.

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension. A. High-density lipoprotein (HDL) level of 70 mg/dL B. A diet high in potassium C. Obstructive sleep apnea (OSA) D. Taking benazepril

Obstructive sleep apnea (OSA) The nurse should include OSA as a risk factor in the development of hypertension. OSA is a condition in which the client's airway becomes blocked by the relaxation of the tongue and muscles of the oropharynx, effectively obstructing the airway. The obstructed airway results in surges in the both the systolic and diastolic pressure during sleep and, in some clients, through the waking hours even when breathing is normal.

A nurse is caring for a group of clients in an infectious disease unit. The nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? Pertussis Mycoplasma pneumonia Tuberculosis Respiratory syncytial virus

Tuberculosis Tuberculosis is transmitted by small droplets. Therefore, nurses providing care to clients who have tuberculosis should wear individually fitted N95 respirator masks.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? Sedation Increased appetite White coating in the mouth Dry oral mucous membranes

White coating in the mouth Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.