Test #1 COTAC 2
Answer: C. Unilateral hearing loss
A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? A. Feeling of pressure in the ear B. Presence of a purulent lesion i n the external ear canal C. Unilateral hearing loss D. Bulging, red, bilateral tympanic membranes
Answer: C. White pupils E. Blurred vision
A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (select all that apply) A. Floating spots B. Eye pain C. White pupils D. Bilateral red reflexes E. Blurred vision
Answer: D Allopurinol Allopurinol is a xanthene oxidase inhibitor that reduces uric acid synthesis. The medication is prescribed to treat gout.
A nurse is caring for a client who has developed gout. Which of the following medications should the nurse prepare to administer? A. Zolpidem B. Alprazolam C. Spironolactone D. Allopurinol
Answer: C. Remind the patient it may take months to restore vision after transplant
A patient who received a corneal transplant 2 weeks ago calls to report that his vision hasn't improved with the transplant. Which action should the nurse take? a)Suggest the patient arrange a ride to the clinic immediately. b)Ask about the presence of "floaters" in the patient' visual field c)Remind the patient it may take months to restore vision after transplant d)Teach the patient to continue using prescribed pupil-dilating medications
Answer: A. a)71-year-old who has noticed increasing loss of peripheral vision.
The nurse working in the vision & hearing clinic receives telephone calls from several clients who want appointments in the clinic ASAP. Which client should be seen first? a)71-year-old who has noticed increasing loss of peripheral vision. b)74-year-old who has difficulty seeing well enough to drive at night c)60-year-old who has difficulty hearing clearly in a noisy environment d)64-year-old who has decreased hearing and ear "stuffiness" without pain.
Farsightedness
hyperopia
nearsighted
myopia
Answer: a)Vertigo
A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? a)Vertigo b)Dysphagia c)Diplopia d)Apraxia
Answer: a)"Without treatment, glaucoma can cause blindness."
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."
Answer: D. "You need to limit your housekeeping activities."
A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You can get water in your eyes in 1 day." C. "You need to tilt your head back when washing your hair." D. "You need to limit your housekeeping activities."
Answer: D. Administer eye drops twice daily
A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Wear an eye patch at night B. Avoid bending at the waist C. Increase intake of deep yellow and orange vegetables D. Administer eye drops twice daily
Answer: D. "Your provider will weight the risks if you have experienced any adverse effects."
A nurse in a clinic is caring for a client who is to receive an immunization. The client asks about contraindications. Which of the following is an appropriate response by the nurse? A. "The use of insulin in a contraindication." B. "The common cold is a contraindication for receiving an immunization." C. "An anaphylactic reaction is a contraindication for administration of any type of immunization.?" D. "Your provider will weight the risks if you have experienced any adverse effects."
Answer: A. Encouraging the client to use nasal saline sprays
For Mikael who is diagnosed of having allergic rhinitis, which nursing intervention is the most appropriate? A. Encouraging the client to use nasal saline sprays B. Discouraging nose blowing before administering nasal medication C. Advising use of bronchodilator regularly, even if having no symptoms D. Instructing the client to carry epinephrine with him at all times
Answer: B. SUDS screening test •SUDS screening test results are available in 30 to 60 minutes. The test is performed on a client to determine if the health care worker with a dirty needle stick injury should begin antiretroviral treatment.
Nurse Vince sustained a dirty needle stick injury. Which diagnostic test would be ordered on a client? A. Enzyme-linked immunosorbent assay (ELISA) B. SUDS screening test C. Antibody titers D. Skin biopsy for Kaposi's sarcoma
Answer: C. Prone so the gas bubble can tamponade the retina
The client has just returned from the operating room for initial recovery after reattachment of the retina. What position will the client be placed in? A. Supine with the head of bed up to protect the airway B. Semi-fowlers with 2 pillows for sniffing position C. Prone so the gas bubble can tamponade the retina D. On the operative side to prevent the retina from slipping sideways
normal vision
Emmetropia
Answer: a)Dim the lights in the patient's room
A 42-year-old woman with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a)Dim the lights in the patient's room b)Encourage increased oral fluid intake c)Change the patient's position every 2 hours d)Keep the head of the bed elevated 30 degrees
Answer: B. Blood C. Vaginal Secretions D. Seminal Fluid
The nurse caring for the patient with HIV-1 would understand the virus is transmitted through which of the following body fluids? (Select all that apply) A. Saliva B. Blood C. Vaginal Secretions D. Seminal Fluid E. Urine
Answer: B. Antibodies
A young man working on his grandfather's farm sustained a deep laceration while working on the fences and requires sutures. His last tetanus shot was over 5 years ago. Based on the information, the client will receive a tetanus booster, which will allow for the release of what? A. Antigens B. Antibodies C. Phagocytes D. Cytokines
Answer: b. "I need something for the pain in my eye. I can't stand it."
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider? a)"My eye really itches, but I'm trying not to rub it." b)"I need something for the pain in my eye. I can't stand it." c)"It's hard to see with a patch on one eye. I'm afraid of falling." d)"The bright light in this room is really bothering me."
Answer: A. Quantitative RNA assay A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.
A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy? A. Quantitative RNA assay B. Platelet count C. Enzyme immunoassay (EIA) test D. Western blot
Answer: D. "Are you pregnant?"
A nurse is preparing to administer a varicella immuniation to a client. Which of the following questions by the nurse is appropriate? A. "Are you allergic to eggs?" B. "Do you have a history of Guillian barre syndrome?" C. "Are you allergic to baker's yeast?" D. "Are you pregnant?"
C) "This medication provides you with an immune response more quickly than your body can produce it."
A nurse is preparing to administer an IM injection of immune globulin to a client who has been exposed to Hepatitis A. Which of the following statements by the nurse is appropriate? A) "This medication offers permanent immunity to hepatitis A. B) " This medication involves three injections over several months. C) "This medication provides you with an immune response more quickly than your body can produce it." D) "This medication contains an attenuated virus to help you body create antibodies."
A)Age of client receiving the vaccine B)Name of vaccine manufacturer C)Vaccine expiration date
A nurse is preparing to document administration of a meningococcal vaccine to a client. Which of the following information should the nurse include in the documentation? (select all that apply) A)Age of client receiving the vaccine B)Name of vaccine manufacturer C)Vaccine expiration date D)Serial number of the E)Serial number of the vaccine
Answer: B. "Clean the incisional site daily after the dressing is removed."
A nurse is providing discharge teaching to a client following an excisional biopsy of a skin lesion. Which of the following information should the nurse include in the teaching? A. "Keep the dressing in place for at least 24 hours." B. "Clean the incisional site daily after the dressing is removed." C. "Use hydrogen peroxide to clean the incisional site." D. "The sutures will be removed in 2 weeks."
Answer: C. "I will cook vegetables before eating them."
A nurse is providing teaching for a client who has stage 3 HIV disease. Which of the following statements by the client should indicate to the nurse an understanding of the teaching? A. "I will rinse raw fruits with water before eating them." B. "I will wear gloves while changing the pet litter box." C. "I will cook vegetables before eating them." D. "I will wear a mask when around family members who are all ill."
Answer: C 10 mm wheal A positive reaction to a tuberculin skin test is an induration (a hardened area) that is 10 mm or greater in diameter. The nurse should measure the area of induration, not any accompanying erythema or swelling.
A nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)? A) 4mm erythema B) 5mm induration C) 10 mm wheal D) 15mm induration
Answer: D. having a decreased ability to perceive colors.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report a)loss of central vision. b)having a loss of peripheral vision. c)seeing bright flashes of light and floaters. d)having a decreased ability to perceive colors.
Answer: B. Older adult woman D. Occupational exposure E. Perinatal exposure
A nurse is assessing a client for HIV. The nurse should identify that which of the following are risk factors assoicated with this virus? (select all that apply) A. Pregnancy B. Older adult woman C. Monogamous sex partner D. Occupational exposure E. Perinatal exposure
Answer: d)Perforated tympanic membrane
A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? a)Mastoiditis b)Ménière's disease c)Acoustic neuroma d)Perforated tympanic membrane
Answer: A. Decreased range of motion B. Pain at rest. C. Recent influenza D. Increased blood pressure
A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expect? ( select all that apply) A. Decreased range of motion B. Pain at rest. C. Recent influenza D. Increased blood pressure E. Hypersalivation
Answer: A. Move head slowly when changing positions B. Plan evenly spaced daily fluid intake C. Reduce exposure to bright lighting E. Avoid fluids containing caffeine
A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (select all that apply) A. Move head slowly when changing positions B. Plan evenly spaced daily fluid intake C. Reduce exposure to bright lighting D. Do not eat fruit high in potassium E. Avoid fluids containing caffeine
Answer: c)The medication should be applied on a regular schedule for the rest of the client's life.
A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide? a)The medication is to be applied when the client is experiencing eye pain. b)The medication will be used until the client's intraocular pressure returns to normal. c)The medication should be applied on a regular schedule for the rest of the client's life. d)The medication is to be used for approximately 10 days, followed by a gradual tapering off.
Answer: c)Avoid blowing the nose
A patient who has undergone a left tympanoplasty should be instructed to: a)Remain on bed rest b)Keep the head of bed elevated c)Avoid blowing the nose d)Irrigate the left ear canal
Answer: c)Administer the medications 5 min apart.
A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide? a)Administer the medications by touching the tip of the dropper to the sclera of the eye. b)Hold pressure on the conjunctiva sac for 2 min following application of drops. c)Administer the medications 5 min apart. d)It is not necessary to remove contact lenses before administering medications.
Answer: D. The client should wear dark glasses while outdoors.
A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? a)Take ibuprofen for eye discomfort. b)Creamy white drainage is an indication of infection. c)Notify the provider immediately if the operative eye itches. d)The client should wear dark glasses while outdoors.
Answer: a)Take an arterial blood gas (ABG) specimen to the laboratory.
A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? a)Take an arterial blood gas (ABG) specimen to the laboratory. b)Transport a client to the radiology department for an x-ray. c)Pass fresh water to clients on the unit. d)Obtain a routine urine sample from a newly-admitted client.
Answer: D. "I will cover up with long-sleeved shirts and pants for the next 5 days."
A 72-year-old patient with age-related macular degeneration (AMD) has just had photodynamic therapy. Which statement by the patient indicated that the discharge teaching has been effective? a)"I will need to use bright light to read for at least the next week" b)"I will use drops to keep my pupils dilated until my appointment" c)"I will not use facial lotions near my eyes during the recovery period." d)"I will cover up with long-sleeved shirts and pants for the next 5 days."
Answer: D. Lyme Disease
A client is being seen in the provider office. He complains of being weak, tired, and has a rash with a consentric circular pattern. What diagnosis does the nurse anticipate? A. systemic erythematous lupus (SLE) B. rhuematoid arthritis (RA) C. rocky mountain spotted fever D. Lyme Disease
Answer: C. "Discard the first bead of ointment before each application."
A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions? a)"Warm the ointment by placing the tube in glass of hot tap water." b)"Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the ointment." c)"Discard the first bead of ointment before each application." d)"Instruct your child to squeeze his eyes shut following application."
Answer: B. CD4-T-cell count 180 cells/mm3 A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.
A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? a) Positive Western blot test b) CD4-T-cell count 180 cells/mm3 c) Platelets 150,000/mm3 d) WBC 5,000/mm3
Answer: a)Place suction equipment at the client's bedside.
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? a)Place suction equipment at the client's bedside. b)Apply an eye patch to the client's right eye. c)Avoid the use of warm water to wash the client's face. d)Provide range-of-motion exercises to the client's neck and shoulders.
Answer: A. Notify the surgeon.
A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority? a)Notify the surgeon. b)Instill an antibiotic solution in both eyes. c)Clean eye from inner to outer canthus. d)Apply a non-pressure patch to the affected eye.
Answer: B. Administer epinephrine intramuscularly
A nurse is caring for a client who received an IVPB of Cefturoxime is now experienceing dyspnea and tongue swelling. Which of the following actions should the nurse perform first? A. Administer epinephrine subcutaneously. B. Administer epinephrine intramuscularly C. Administer epinephrine through an intravenous piggyback D. Administer IV push epinephrine immediately.
Answer: B The medication should be discontinued 3 months prior to a planned pregnancy. Methotrexate should be discontinued 3 months prior to planning a pregnancy and should not be resumed after birth, if a client is breast feeding.
A nurse is caring for a female client who has rheumatoid arthritis and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client? A. Dietary modifications occur during pregnancy when taking this medication. B. The medication should be discontinued 3 months prior to a planned pregnancy. C. Dosage of the medication will be reduced during pregnancy. D. The client can breast feed when taking this medication.
Answer: C. Open-angle glaucoma
A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Angle-closure glaucoma C. Open-angle glaucoma D. Macular degeneration
Answer: A. A 20 year old newly married female. B. A 35 year old female who is going through infertility treatments to conceive D. A 24 year old mother of a two month old nursing infant
A nurse is conducting a class on methods of management to a group of clients from an Rheumatoid arthritis clinic. Methods for relaxation, managing symptoms included teaching on medications. Which of the following clients would not be a candidate for methotrexate? (select all that apply) A. A 20 year old newly married female. B. A 35 year old female who is going through infertility treatments to conceive C. A 42 year old female with previous hyterectomy for uterine cancer D. A 24 year old mother of a two month old nursing infant
Answer: A. Instruct the client to avoid raw foods, and fresh fruits and vegetable that cannot be washed well. B. Avoid IM injections when possible. C. Don a mask, gloves, and gown E. Restrict visitors who have an active cough or runny nose
A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.) A. Instruct the client to avoid raw foods, and fresh fruits and vegetable that cannot be washed well. B. Avoid IM injections when possible. C. Don a mask, gloves, and gown D. Limit visitors to 5 minutes only E. Restrict visitors who have an active cough or runny nose
A. Diuretic use B. Deep sleep deprivation D. Cardiovascular disease E. Obesity
A nurse is discussing gout with a client who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? (select all that apply) A. Diuretic use B. Deep sleep deprivation C. Depression D. Cardiovascular disease E. Obesity
Answer: a)Turn the client's head to the side.
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? a)Turn the client's head to the side. b)Check the client's motor strength. c)Loosen the clothing around the client's waist. d)Document the time the seizure began.
Answer: a)"Apply the ointment in a thin line into the conjunctival sac."
A nurse is instructing the caregiver of a toddler who has bacterial conjunctivitis and a new prescription for an ophthalmic ointment. Which of the following instructions should the nurse provide? a)"Apply the ointment in a thin line into the conjunctival sac." b)"Ask the child to look down before applying the ointment." c)"Always wipe from the outer to the inner canthus when wiping away secretions." d)"Use a sterile glove and applicator to apply the antibiotic ointment."
Answer: c)Transferring a client to the discharge location
A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse? a)Preventing cross-contamination of clients b)Performing concise client assessment c)Transferring a client to the discharge location d)Maintaining a client tracking system
B) Aske the client about previous reactions to allergens. C) Ask the client about medications she took over the past several days. D) Inform the client to expect itching at one site. E) Obtain emergency resuscitation equipment.
A nurse is preparing to administer a scratch test to a client who has possible food and environmental allergies. Which of the following actions should the nurse perform prior to the procedure? (select all that apply) A) Cleanse the client's skin with povidone-iodine. B) Aske the client about previous reactions to allergens. C) Ask the client about medications she took over the past several days. D) Inform the client to expect itching at one site. E) Obtain emergency resuscitation equipment.
Answer: B. "I need to increase my fluid intake while taking this medication." Clients who have gout should increase their fluid intake to 2 to 3L per day to prevent toxicity of allopurinol and decrease uric acid levels. Clients can develop a toxicity syndrome a few weeks after they start therapy with this drug, which includes rash, fever, eosinophilia and liver and kidney dysfunction so rash and aspirin are not correct. Allopurinol can be taken with or without food but food can increase GI adverse effects.
A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. Which of the following statements by the client indicates an understanding of the teaching? A. "If I get a rash from this medication, I will take my usual antihistamine." B. "I need to increase my fluid intake while taking this medication." C. "I should take this medicine on an empty stomach." D. "If I get a fever while taking this medication, I will take some aspirin."
Answer: B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week.
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.
Answer: C. "I should eat more bananas while taking this medication." The nurse should instruct the client to eat more potassium-rich foods such as bananas and citrus fruits while taking this medication. Prednisone can cause a loss of potassium, and the nurse should instruct the about the manifestations of hypokalemia such as muscle weakness and cramping and to notify the provider should these occur.
A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take my flu vaccine within one week of starting this medication." B. "I can expect a sore throat for the first week after starting this medication." C. "I should eat more bananas while taking this medication." D. "I should take aspirin for minor aches and pains while taking this medication."
C. Enlarged adenoids E. Report of recent colds
A nurse is reviewing the health record of a client with severe otitis media. Which of the following are expected findings? (select all that apply) A. Light reflex visible on the otoscopic exam in the affected ear B. Client prescription for daily furosemide C. Enlarged adenoids D. Ear pain relieved by meclizine E. Report of recent colds
C. Lymphocytes
A nurse is reviewing the laboratory findings of a client who has measles. The nurse should expect to find an increase in which of the following types of WBCs? A) Neutrophils B) Basophils C) Lymphocytes D) Eosinophils
Answer: b)Restrict head movement.
A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include? a)Keep both eyes patched. b)Restrict head movement. c)Eye drops to constrict the pupils will be prescribed. d)Apply cool compresses.
Answer: a)More difficulty seeing due to a greater sensitivity to glare b)Decreased cough reflex c)Decreased bladder capacity e)Dehydration of intervertebral discs
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.) a)More difficulty seeing due to a greater sensitivity to glare b)Decreased cough reflex c)Decreased bladder capacity d)Decreased systolic blood pressure e)Dehydration of intervertebral discs
Answer: B. "I should use a mild hair shampoo."
A nurse is teaching a client who has SLE about self-care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will inspect my skin once a month for rashes." B. "I should use a mild hair shampoo." C. "I should limit my time to 10 minutes in the taning bed." D. "I will apply powder to any skin rash."
Answer: B. "Notify the provider if the diarrhea gets uncontrollable." The medication can cause diarrhea. The client should report if gastric problems occur including N/V as the med is DC'd if it occurs. Bruising and bleeding is considered an adverse effect of this medication and grapefruit juice can interfere with the metabolism of this medication and increase the risk of toxicity
A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include? A. "Take this medication with food if nausea develops." B. "Notify the provider if the diarrhea gets uncontrollable." C. "Expect to have increased bruising." D. "Increase your intake of grapefruit juice."
Answer: B. Decreases inflammation Prednisone is used to treat rheumatoid arthritis because it produces anti-inflammatory and immunosuppressive effects, which reduces inflammation, decreases pain, and increases mobility.
A nurse is teaching a client who has a new prescription for prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication? A. Reduces risk of infection B. Decreases inflammation C. Improves peripheral blood flow D. Increases bone density
Answer: D Exercise Deconditioning and muscle atrophy occurs as a result of lack of mobility. The nurse should encourage client to engage in conditioning exercises alternated with periods of rest.
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? A. Sunlight B. Pregnancy C. Infection D. Exercise
Answer: c)A middle adult male who is diaphoretic and reports epigastric pain
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately? a)An adolescent female client who is belligerent and has slurred speech b)A toddler who has a laceration on his forehead and is screaming c)A middle adult male who is diaphoretic and reports epigastric pain d)A young adult with a painful sunburn of his face and arms
Answer: B
A nurse suspects anaphylaxis when caring for a client following the initial administration of an oral antibiotic. Which of the following should be the nurse's priority intervention? A. Insert an IV line. B. Count the respiratory rate. C. Administer oxygen. D. Prepare equipment for intubation.
Answer: B. Administering I.M. epinephrine per protocol
After the first injection of an immunotherapy program, the nurse notices a large, red wheal on the client's arm, coughing, and expiratory wheezing. Which intervention should the nurse implement first? A. Notifying the health care provider immediately B. Administering I.M. epinephrine per protocol C. Beginning oxygen by way of nasal cannula D. Starting an I.V. line for medication administration
Answer: C. "Wear large-brimmed hats when exposed to the sun."
April is diagnosed with systemic lupus erythematosus. Which instruction would be included in the teaching plan for the client? A. "Remove all rugs, curtains, and dust-collecting items in home." B. "Carry injectable epinephrine at all times in case of exacerbation." C. "Wear large-brimmed hats when exposed to the sun." D. "Use tanning beds instead of sunbathing outside."
Answer: A. "Wear large-brimmed hats when exposed to the sun." The client diagnosed with systemic lupus erythematosus needs to modify his lifestyle. This includes avoiding sun and ultraviolet light exposure, especially between the hours of 10 a.m. and 4 p.m. The client also should wear tightly woven clothing.
April is diagnosed with systemic lupus erythematosus. Which instruction would be included in the teaching plan for the client? A. "Wear large-brimmed hats when exposed to the sun." B. "Use tanning beds instead of sunbathing outside." C. "Remove all rugs, curtains, and dust-collecting items in home." D. "Carry injectable epinephrine at all times in case of exacerbation."
distortion caused by irregularity of the cornea
Astigmatism
Answer: A. sleep disturbances C. widespread, bilateral, musculoskeletal pain E. Multiple tender points
During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report which of the following? (select all that apply) A. sleep disturbances B. multiple joint pains with inflammation and swelling C. widespread, bilateral, musculoskeletal pain D. Cardiac palpitations E. Multiple tender points
Answer: a)The patient has a temperature of 100.6 F
The nurse is assessing a patient who has recently been treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? a)The patient has a temperature of 100.6 F b)The patient complains of "popping" in the ear c)The patient frequently asks the nurse to repeat information d)The patient states that the right ear has a feeling of fullness.
Answer: a)Notify the physician
The nurse is caring for a client following enucleation. The nurse notes the presence of bright red blood drainage on the dressing. Which nursing action is appropriate? a)Notify the physician b)Continue to monitor the drainage c)Document the finding d)Mark the drainage on the dressing and monitor for any increase in bleeding.
Answer: B. A phlebotomist working in an acute care hospital E. The unborn infant of an HIV mother
The nurse working in healthcare must recognize the transmission potential for HIV. Which of the following clients are at risk for exposure to HIV. A. A man who has just discovered his attraction for the same sex but has not acted on it. B. A phlebotomist working in an acute care hospital C. The best friend of an HIV postive female D. A 14 year old young man who discovered several partners with the same desires at a summer camp. E. The unborn infant of an HIV mother
Answer: c. Hypersensitivity
The patient presents with complaints of severe urticaria and large hives over the chest and arms. When questioned about the use of any new products the wife admits she started using a new laundry soap. The nurse would note which of the following on the patient chart? A. Autoimmunity B. Natural Immunity C. Hypersensitivity D. Anaphylaxis
Answer: a)Risk for falls related to dizziness
The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is: a)Risk for falls related to dizziness b)Impaired verbal communication related to tinnitus c)Self-care deficit (bathing & dressing) related to vertigo d)Imbalanced nutrition: less than body requirements related to nausea
Answer: C. They are potentially experiencing a detached retina
The student next to you cries out and when asked what is wrong indicates they are seeing flashing lights, and a large amount of floaters in their eye. What is possibly occurring with this student? A. They have suddenly remembered they haven't eaten B. They are in a panic as they know they have to take one more of your exams. C. They are potentially experiencing a detached retina D. They forgot to let the dog out and are sure there is going to be a mess when they get home.
Answer: b)Use a Snellen chart to check a patient's visual acuity
Which action could the register nurse (RN) who is working in the eye and ear clinic delegate to a licensed practical/vocational nurse (LPN/LVN)? a)Evaluate a patient ability to administer eye drops b)Use a Snellen chart to check a patient's visual acuity c)Teach a patient with otosclerosis about use of sodium fluoride and vitamins D. d)Check the patient's external ear for signs of irritation caused by a hearing aid.
Answer: A. Joint edema and tenderness Clinical features of systemic lupus erythematosus involve multiple body systems. When the musculoskeletal system is involved, the client exhibits joint tenderness, edema, and morning stiffness.
Which clinical manifestation would cause the nurse to suspect that the client is diagnosed with systemic lupus erythematosus? A. Joint edema and tenderness B. Red, burning, tearing eyes C. Chest tightness with wheezing on expiration D. Fever and night sweats
Answer: b)The patient's oral temperature is 100.8 F (38.1 C)
Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? a)The patient complains of "fullness" in the ear. b)The patient's oral temperature is 100.8 F (38.1 C) c)The patient says "My hearing is worse now than it was right after surgery."" d)There is a small amount of dried bloody drainage on the patient's dressing.
Answer D. Tonometer A tonometer is a device used in glaucoma screening to record intraocular pressure.
Which of the following instruments is used to record intraocular pressure? a)Goniometer b)Ophthalmoscope c)Slit lamp d)Tonometer
Answer: B. The nurse neglected to have the client occlude the puncta after eye drop administration
You are precepting with a nurse and she asks you to go take the vital signs on another client while she administers the timoptic eye drops. 15 minutes later you note the clients heart rate on the monitor has decreased to 55. What practice related to the eye drop administration might have influenced the client's heart rate? A. The nurse administered the eye drops too quickly B. The nurse neglected to have the client occlude the puncta after eye drop administration C. The nurse neglected to have the client hold their head back for 5 minutes after administration D. The nurse administered the eye drops into the conjunctival sac
Answer: A. Irrigate the eye with sterile normal saline
The client arrives in the emergency room after sustaining a chemical eye injury from a splash of battery acid. The initial nursing action is to: a)Begin visual acuity testing b)Irrigate the eye with sterile normal saline c)Swab the eye with antibiotic ointment d)Cover the eye with a pressure patch.
Answer: B. Weber test
The client asks the nurse to speak into his right ear, stating, "that's the good one'. What test wound be conducted on this client to validate unilateral hearing loss? A. Western test B. Weber test C. Rhinne test D. Waver test
Answer: A. Monitor the IV and assess I & O B. Assess the clients morning laboratory values for BUN & Creatinine D. Explain to the client the color of their urine may change for up to 24 hours after the procedure E. Encourage the client to increase their fluid intake after the procedure
The client has is preparing for angiography on the eye. What actions are appropriate for the nurse to take? (select all that apply) A. Monitor the IV and assess I & O B. Assess the clients morning laboratory values for BUN & Creatinine C. Make sure the client has been NPO after midnight D. Explain to the client the color of their urine may change for up to 24 hours after the procedure E. Encourage the client to increase their fluid intake after the procedure
Answer: C. Amsler grid
The client is being followed for potential macular degeneration. What is the most specific examination that will be assessed? A. Slit-lamp examination B. Color vision testing C. Amsler grid D. Optical coherence tomography
Answer: C. Talking in a louder voice to help the client hear
The client who is hearing impaired is able to read lips for communication. The student nurse is completing the admission assessment. After the assessment is complete the nurse complimented the student on her choices for interaction. What actions would the nurse refrain from commenting on? A. The student sat directly in front of the client while speaking. B. The student spoke slowly and distinctly, pausing frequently C. Talking in a louder voice to help the client hear D. The student shared the admission form prior to beginning so the client would know what was being discussed.
Answer: B The right eye is tested followed by the left eye, and then both eyes are tested. Visual acuity is assessed in one eye at a time, and then in both eyes together with the client comfortably standing or sitting. The right eye is tested with the left eye covered; then the left eye is tested with the right eye covered. Both eyes then are tested together. Visual acuity is measured with or without corrective lenses and the client stands at a distance of 20ft. from the chart.
The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test? a)Both eyes are assessed together, followed by the assessment of the right and then the left eye. b)The right eye is tested followed by the left eye, and then both eyes are tested. c)The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart. d)The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.
Answer: D. CD4
The nurse as a member of the care team for a patient with HIV-1 would relate which of the following tests to the physician to identify viral load and level of immune dysfunction? A. RBCs B. CBC C. WBCs D. CD4
Answer: B. Identify items on the clients meal tray using a clock face ex: the milk is at 9 o'clock your coffee is at 1 o'clock C. Make sure the client is oriented to furniture in the room upon admission, and then do not change furniture position D. Identify the position of the call light, the client cell phone, tissues, water etc. prior to leaving the room.
The nurse caring for a client who is legally blind would utilize which of the following strategies to interact with the client? A. Talk louder than usual to the patient from the door to alert them you are coming in B. Identify items on the clients meal tray using a clock face ex: the milk is at 9 o'clock your coffee is at 1 o'clock C. Make sure the client is oriented to furniture in the room upon admission, and then do not change furniture position D. Identify the position of the call light, the client cell phone, tissues, water etc. prior to leaving the room. E. Never touch the client as they are startled and won't like you entering their space.