Chapter 10 prioritaztion
Phenylephirne, and adrenergic agonist has been prescribed as a topical application for a client as an aid to intraocular surgery. Although systemic toxicicty is unlikely, which aders physiologic response is the greatest concern 1. cardiovasuclar response, such as hypertension or ventricluar dysrhythmias 2. renal response, such as urinary retention and incontinence 3. Respiratory response such as bronchospasm or mucous plugs 4. musculoskelatal response such as bone or joint stiffness.
1
The client reports tinnitus. The nurse decides to review the client's med list to determine if any meds may be causin or contributing to this adverse effect. Which combination of drugs is caus for greatest concern 1. Gentamycin and ethacrynic acid 2. furosemide and metoprolol 3. vanc and nitorglycerin patch 4. asperin and calcium supplment
1
The nurse is working in a community health clinic and a client needs instructions for the care of a stye on the right upper eyelid. What is the first intervent that the client should try 1. apply warm compresses four time per day 2. gently perform hygienic eyelid scrubs 3. obtain a prescription for antibiotic drps 4. contact the ophthalmologist
1
the nurse is intervewing an older adult client who reports that "lately there has been a roaring sound in my ears" What additional assessments should the nurse include SATA 1. obtain a med history 2. ask about exposure to loud noises 3. observe the canal for earwax or foreign body 4. assess for signs and symptoms of ear infection 5. ask about method of ear hygiene 6. ask about diet and nutrition
1,2,3,4,5
A cheerful older widow comes to the community clinic for her annual check up. She is reasonably good hefalth, but she has a hearing loss of 40 dB. She confides, " I don't get our much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarassing." What is the priority nursing concept to consider in planning care for this client 1. cognition 2. sensory perception 3. mood and affect 4. anxiety
2
The nurs is supervising a new nruse who has just finished assessing a cleitn for redness and discomfort to the right eye. The new nurse documents "visual acuity N/A" What should the supervising nurse do 1. do nothing, the documentation is minimal but acceptable 2. ask her to explain the rationale for the documentation 3. reassess the client's eye and vision to validate findings 4. suggest contacting the clinical educator for documentation tips
2
The nurse is interviewing an older woman and discovers that she has been taking her glaucoma eyedrops by mouth for the past week. What should the nurse do first 1. obtain a prescription for tonometry so that her intraocular pressure can be checked 2. try to determin how frequently and how much she has been ingesting 3. ask her how she decided to take the drops orally instead of instilling them as eyedrops 4. call the poison control center and be prepared to describe untoward side effects
2
The nurse is working in a clinic that specializes in care of clients with ear disorders. a client tells the nurse that he has been taking meclizine Which question is the nurse most likely to ask to evaluate the effectiveness of the med 1. has the med helped to relieve the pain in the ear canal 2. are you still experienceg the whiling and turning sensation 3. have you been able to hear better since you started the med 4. are you still having itching and discomfort in the outer ear
2
a SN is assisting an older client who is alert, conversant, and cognitively intact. The client has decreased vision related to macular degeneration. When would the supervising nurse intervene 1. student puts call bell and personal items within reach and locates each item by guiding the client's hand 2. student closes the curtains and turns off all of the lights at the endo f shift to encourage rest and sleep 3. student talks to the client about family and asks "so, when was the last time you saw your uncle?" 4. Student assists durgin mealtime by opeing packages and dexsribing location of foods by using clock coordinates
2
At a community health clinic, the nurse is teaching a community group about the prevention of accidental eye injuries. What is the most important thing to stress 1. workplace policies for handling chemicals should be followed 2. children and parents should be caustious abut aggressive play 3. protective eyewear should be worn during sports or hazardous work 4. emergency eyewash stations should be established in the workplace
3
The nruse is on a camping trip. A man is chopping wood and gets struck in the eye with a peice of debris. On exam, a wood splinter is protruding from his eyeball. What should the nurse do first? 1. hae the man lie in the back seat of the car and dribe him to the ed 2. gently remove the peice of wood and place a sterile dressing over the eye 3. stabilize the area by carefully resting a plastic on the orbital rim and taping it in place 4. flush the eye with copius amount os clean tepid water, then check visual acuity
3
The nurse is working in a n ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should the nurse direct the caller to do first? 1. please call your health care provider 2. apply a cool compress to your eyes 3. If you are wearing contact lenses, remove them 4. take an over the counter antihistamine
3
The nurse performed postop stapedectomy teaching several days ago for a client. Which comment by the client is cause for greatest concern 1. im going to take swimming lessons in a couple of months 2. i have to take a ong oversease flight in several weeks 3. i Can't wait to get back to my regular weightlifting class 4. I have been coughing a lot with my mouth open
3
Which physical assessment findings should be reported to the HCP 1. pearly gray or pink tympanic membrane 2. dense whitish ring at the circumference of the tympanum 3. Bulging red or blue tympanic membrane 4. cone of light at the innermost part of the tympanum
3
After caratrct sufgery , the client experinces all of the symptoms listed below. Which symptom needs to be immediately reported 1. a scratchy sensaionin the operative eye 2. loss of depth perception with the patch in place 3. poor vision 6-8 hours after patch removal 4. pain not relieved y prescribed meds
4
The nurse is caring for several clients who are having problems with their ears. Whcih client condition is cause for greatest concern. 1. Has discomfort of the ear preceded by a viral infection the tympanic membrane is erythematous 2 has been treated with antibiotics for recurrent acute otitis media four times within the past 6 months 3. reprots rapid onset ear pain and pruitis and a sensation of ullness that started after cleaning the ear canal with a finger 4. reports progressive severe otic pain with purulent dischrage and is positive for HIV
4
Which finding should be immediatly reported to the HCP 1. a change in color vision 2. crusty yellow draingage on the eyelashes 3. increased lacrimation 4. a curtainlike shadow across the visual field.
4
AFter examining the client's ear canal with an otoscope, the health care provider instructs the nurse to irrigate the ear canal. Place the following steps for ear irrigation in the correct order 1. place the tip of the syringe at an angle int he esternal canal 2. watch for fluid return and signs of cerumen 3. if cerumen does not appear, wait 10 minutes and repeat the irrigation 4. fill a syringe with warm irrigating solution 5. after completion of the irrigation, have the client turn the head to the side to facilitate drainage 6. apply gentle but continous pressure to the syringe plunger
4,1,6,2,5,3
Place the following steps for eyedrop administration in order 1. gently press on the lacrimal duct for 1 minute 2. gently pull tissue underneath eye downward to expose lower conjunctival sac 3. have the client gently close the eye and move it aroung 4. have the client look up and instill the number of prescribed drops 5. hold the dropper and stabilize hand on the client's forehead 6. have the client sit down and tilt his or her head slightly backward
6,2,5,4,3,1
