Unit 4 Part 2

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would be noted to support a diagnosis of glaucoma? 1 Blurred central vision 2 Increased opacity of the lens 3 Elevated intraocular pressure 4 Changes in retinal blood vessels

Elevated intraocular pressure

Which response reported by an older adult client would the nurse identify as consistent with the diagnosis of macular degeneration? 1 "My vision is best when I dim the lights." 2 "I always see halos around lights, especially at night." 3 "I can't see objects in my periphery vision." 4 "I can't see objects in the center of my vision field."

"I can't see objects in the center of my vision field."

The nurse is caring for a client admitted with fluid overload. Which tasks are most appropriate to be delegated to the patient care associate (PCA)? Select all that apply. One, some, or all responses may be correct. 1 Documenting vital signs 2 Recording urine output 3 Assessing the laboratory findings 4 Administering diuretic intravenously 5 Repositioning the client every 1 or 2 hours

1 Documenting vital signs 2 Recording urine output 5 Repositioning the client every 1 or 2 hours

Which nursing assessment findings are consistent with fluid volume overload from high-flow intravenous (IV) fluid replacement therapy? Select all that apply. One, some, or all responses may be correct. 1 Pulse quality 2 Pulse pressure 3 Bounding pulse 4 Presence of dependent edema 5 Neck vein distention in the upright position

3 Bounding pulse 4 Presence of dependent edema 5 Neck vein distention in the upright position

A client has phosphate renal calculi. Which food item would the nurse teach the client to include regularly in the diet? 1 Apples 2 Chocolate 3 Rye bread 4 Cheddar cheese

Apples

The nurse assesses an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? 1 Sunken eyes 2 Dry, flaky skin 3 Change in mental status 4 Decreased bowel sounds

Change in mental status

Which assessment would the nurse use to evaluate the severity of dehydration in a hospitalized infant with dry mucous membranes, absence of tears when the infant cries, and poor skin turgor? 1 Daily serum electrolytes 2 Respiratory rate and rhythm 3 Change in weight from prior measurement 4 Alterations in heart sounds since admission

Change in weight from prior measurement

The symptoms of four clients with different levels of impaired vision are given in the chart.Which client is expected to be diagnosed with macular degeneration? 1 Client A. (impaired near vision) 2 Client B. (loss of central vision) 3 Client C. (cross appearance of eyes) 4 Client D. (inability to see distant objects)

Client B. (loss of central vision)

Which treatment goal would the nurse emphasize when teaching a client with a diagnosis of open-angle glaucoma? 1 Dilate the pupil. 2 Rest the eye muscles. 3 Control intraocular pressure. 4 Prevent secondary infections.

Control intraocular pressure.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis of nailbeds

Crackles in the lungs

Which nursing assessment indicates dehydration in an infant? 1 Flat anterior fontanel 2 Decreased urine output 3 Warm skin temperature 4 Slow, labored respirations

Decreased urine output

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/h. One hour later, the client begins screaming, "I can't breathe!" How would the nurse respond? 1 Discontinue the IV and notify the health care provider. 2 Elevate the head of the client's bed and obtain vital signs. 3 Assess the client for allergies and change the IV to an intermittent lock. 4 Contact the health care provider to request a prescription for a sedative.

Elevate the head of the client's bed and obtain vital signs.

Which intervention would prevent urinary stasis and formation of renal calculi in an immobile client? 1 Increasing oral fluid intake to 2 to 3 L/day 2 Maintaining bed rest after discharge 3 Limiting fluid intake to 1 L/day 4 Voiding at least every hour

Increasing oral fluid intake to 2 to 3 L/day

To prevent the development of ureteral colic from renal calculi in the future, which strategy would the nurse include in the client's plan of care? 1 Instruct the client to drink at least 3 L of fluid daily. 2 Suggest interventions to decrease the serum creatinine level. 3 Establish a urinary output goal of 2000 mL per 24 hours. 4 Teach the client to exclude milk products from their diet.

Instruct the client to drink at least 3 L of fluid daily.

A client with a femoral fracture and osteomyelitis is immobilized for 3 weeks. Which rationale explains the nurse's plan to assess for the development of renal calculi? 1 The client's dietary patterns have changed since admission. 2 The client has more difficulty urinating in a supine position. 3 Lack of weight-bearing activity promotes bone demineralization. 4 Fracture healing requires more calcium, which increases calcium metabolism.

Lack of weight-bearing activity promotes bone demineralization.

Which rationale would the nurse include in teaching a client with glaucoma about the need for treatment? 1 Surgery helps temporarily. 2 Total blindness is inevitable. 3 Use of both eyes is restricted. 4 Lost vision cannot be restored.

Lost vision cannot be restored.

Which clinical manifestation is indicative of the fluid and electrolyte imbalance associated with a parathyroidectomy? 1 Constipation 2 Muscle spasms 3 Hypoactive reflexes 4 Increased specific gravity

Muscle spasms

An 11-month-old is admitted with dehydration and a serum sodium level of 120 mEq/L (120 mmol/L). Which assessment finding would be the priority to report to the health care provider? 1 Weight loss of 1.5 kg in 3 days 2 Muscle twitching in all extremities 3 Temperature increase to 100°F (37.8°C) 4 Heart rate increasing from 100 to 120 beats per minute

Muscle twitching in all extremities

A client has primary open-angle glaucoma. Which ophthalmic preparation is indicated to manage this condition? 1 Tetracaine 2 Fluorescein 3 Timolol maleate 4 Atropine sulfate

Timolol maleate

After an unsuccessful lithotripsy to break up renal calculi, a nephrolithotomy was successful in removing the client's renal calculi. Which clinical indicator would the nurse monitor during the postoperative period and report immediately to the primary health care provider? 1 Continuous passage of pink-tinged urine 2 Pink drainage on the client's surgical dressing 3 Total intake volume of 2000 mL in 24 hours 4 Urinary output of 20 to 30 mL/h

Urinary output of 20 to 30 mL/h