Unit 7
The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history, physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first? Select one: a.Check the patient's blood glucose level. b.Take the blood pressure on the left arm. c.Use an irrigating syringe to clean the ear canals. d.Report a vision change to the health care provider.
d.Report a vision change to the health care provider.
A patient asks about using minoxidil (Rogaine) for hair thinning. Which statement about minoxidil is accurate? Select one: a.The product is applied once daily in the morning. b.Systemic absorption of topically applied minoxidil is rare. c.Results may be seen as soon as 2 weeks after beginning therapy. d.Systemic absorption may cause tachycardia, fluid retention, and weight gain.
d.Systemic absorption may cause tachycardia, fluid retention, and weight gain.
The nurse is administrating eardrops that have been refrigerated. Which action by the nurse is correct before administering the drops? Select one: a.Leave the drops in the refrigerator until use. b.Heat the chilled solution for 10 seconds in the microwave. c.Soak the bottle for 60 seconds in a container of very hot water. d.Take the drops out of the refrigerator 1 hour before the dose is due.
d.Take the drops out of the refrigerator 1 hour before the dose is due.
Which finding in an emergency department patient who reports being struck in the right eye with a fist is a priority for the nurse to communicate to the health care provider? Select one: a.The patient complains of a right-sided headache. b.The sclera on the right eye has broken blood vessels. c.The area around the right eye is bruised and tender to the touch. d.The patient complains of "a curtain" over part of the visual field.
d.The patient complains of "a curtain" over part of the visual field.
The nurse at the eye clinic made a follow-up telephone call to a patient who underwent cataract extraction and intraocular lens implantation the previous day. Which information is the priority to communicate to the health care provider? Select one: a.The patient requests a prescription refill for next week. b.The patient feels uncomfortable wearing an eye patch. c.The patient complains that the vision has not improved. d.The patient reports eye pain rated 5 (on a 0 to 10 scale).
d.The patient reports eye pain rated 5 (on a 0 to 10 scale).
A 65-yr-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patient's treatment plan? Select one: a."I take metoprolol (Lopressor) for angina." b."I take aspirin when I have a sinus headache." c."I have had frequent episodes of conjunctivitis." d."I have not had an eye examination for 10 years."
"I take metoprolol (Lopressor) for angina." It is important to note whether the patient takes any b-adrenergic blockers because this classification of medications is also used to treat glaucoma, and there may be an increase in adverse effects. The use of aspirin does not increase intraocular pressure and is safe for patients with glaucoma. Although older patients should have yearly eye examinations, the treatment for this patient will not be affected by the 10-year gap in eye care. Conjunctivitis does not increase the risk for glaucoma.
A child has been diagnosed with impetigo, a skin infection. The nurse anticipates that which drug will be used to treat this condition? Select one: a.Spinosad (Natroba) b.Nystatin (Mycostatin) c.Acyclovir (Zovirax) d.Bacitracin
d.Bacitracin
A patient with Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? Select one: 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 45 degrees.
a. Dim the lights in the patient's room.
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? Select one: a.Thinning of the affected skin b.Alopecia of the affected areas c.Dryness and scaling in the area d.Reddish-brown skin discoloration
a. Thinning of the affected skin
A 75-yr-old patient who lives alone at home tells the nurse, "I am afraid of losing my independence because my eyes don't work as well they used to." Which action should the nurse take first? Select one: a.Discuss the increased risk for falls that is associated with impaired vision. b.Ask the patient about what type of vision problems are being experienced. c.Explain that there are many ways to compensate for decreases in visual acuity. d.Suggest ways of improving the patient's safety, such as using brighter lighting.
Ask the patient about what type of vision problems are being experienced. The nurse's initial action should be further assessment of the patient's concerns and visual problems. The other actions may be appropriate, depending on what the nurse finds with further assessment.
A nurse should include which instructions when teaching a patient with repeated hordeolum how to prevent further infection? Select one: a.Apply cold compresses. b.Discard used eye cosmetics. c.Wash the scalp and eyebrows with an antiseborrheic shampoo. d.Be examined for recurrent sexually transmitted infections (STIs).
Discard used eye cosmetics. Hordeolum (styes) are commonly caused by Staphylococcus aureus, which may be present in cosmetics that the patient is using. Warm compresses are recommended to treat hordeolum. Antiseborrheic shampoos are recommended for seborrheic blepharitis. Patients with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be referred for STI testing.
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? Select one: a.Place the right arm and hand flexed in a position of comfort. b.Elevate the right arm and hand on pillows and extend the fingers. c.Assist the patient to a supine position with a small pillow under the head. d.Position the patient in a side-lying position with rolled towel under the neck.
Elevate the right arm and hand on pillows and extend the fingers. The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow or rolled towel because the head should be maintained in an extended position in order to avoid contractures.
A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? Select one: a.History of sun exposure by the patient b.Method of contraception used by the patient c.Length of time the patient has used fluorouracil d.Appearance of the treated areas on the patient's face
Method of contraception used by the patient Because fluorouracil is teratogenic, it is essential that the patient use a reliable method of birth control. The other information is also important for the nurse to obtain, but lack of reliable contraception has the most potential for serious adverse medication effects.
When teaching a patient about the proper application of timolol (Timoptic) eyedrops, the nurse will include which instruction? Select one: a."Apply the drops into the conjunctival sac instead of directly onto the eye." b."Apply the drops directly to the eyeball (cornea) for the best effect." c."Blot your eye with a tissue immediately after applying the drops." d."Tilt your head forward before applying the eyedrops."
a."Apply the drops into the conjunctival sac instead of directly onto the eye."
The nurse is providing health promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? Select one: a.A Tono-Pen will be applied to the surface of the eye. b.The test involves reading a Snellen chart from 20 feet. c.Medications will be used to dilate the pupils for the test. d.The examination involves checking the pupil's reaction to light.
a.A Tono-Pen will be applied to the surface of the eye.
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? Select one: a.Auscultate the patient's lung sounds. b.Determine the extent and depth of the burns. c.Give the prescribed hydromorphone (Dilaudid). d.Infuse the prescribed lactated Ringer's solution.
a.Auscultate the patient's lung sounds.
A child has been diagnosed with bacterial otitis externa and will be receiving eardrops. Which of these eardrops are appropriate for this infection? (Select all that apply.) Select one or more: a.Floxin Otic b.Cortic c.Debrox d.Acetasol HC e.Cipro HC Otic
a.Floxin Otic e.Cipro HC Otic
A 55-year-old obese patient was diagnosed with candidiasis in the skin folds under her breasts. When the nurse sees her at a follow-up visit 2 months later, she complains that it has returned. She said she applied the medicine for 1 week and stopped because the itching stopped and the cream was messy. Which statement is true regarding fungal infections of the skin? Select one: a.Fungal infections often require prolonged therapy. b.The patient has a new infection now. c.The patient needs to apply a dressing if the cream is too messy. d.This infection will probably never be cured.
a.Fungal infections often require prolonged therapy.
Assessment of a patient's visual acuity reveals that the left eye can see at 20 feet what a person with normal vision can see at 50 feet and the right eye can see at 20 feet what a person with normal vision can see at 40 feet. The nurse records which finding? Select one: a.OS 20/50; OD 20/40 b.OU 20/40; OS 50/20 c.OD 20/40; OS 20/50 d.OU 40/20; OD 50/20
a.OS 20/50; OD 20/40
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? Select one: a.Prepare the patient for a skin biopsy. b.Teach the use of corticosteroid cream. c.Explain how to apply tretinoin (Retin-A) to the face. d.Discuss the need for topical application of antibiotics.
a.Prepare the patient for a skin biopsy.
The nurse developing a teaching plan for a patient with herpes simplex keratitis should include which instruction? Select one: a.Wash hands frequently and avoid touching the eyes. b.Apply antibiotic drops to the eye several times daily. c.Apply a new occlusive dressing to the affected eye at bedtime. d.Use corticosteroid ophthalmic ointment to decrease inflammation.
a.Wash hands frequently and avoid touching the eyes.
The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is Select one: a.risk for falls related to episodic dizziness. b.impaired verbal communication related to tinnitus. c.self-care deficit (bathing and dressing) related to vertigo. d.imbalanced nutrition: less than body requirements related to nausea.
a.risk for falls related to episodic dizziness.
During the preoperative assessment of a patient scheduled for a right cataract extraction and intraocular lens implantation, it is important for the nurse to assess Select one: a.the visual acuity of the patient's left eye. b.how long the patient has had the cataract. c.for presence of a white pupil in the right eye. d.for a history of reactions to general anesthetics.
a.the visual acuity of the patient's left eye.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? Select one: a.Administer vitamins and minerals intravenously. b.Insert a feeding tube and initiate enteral feedings. c.Infuse total parenteral nutrition via a central catheter. d.Encourage an oral intake of at least 5000 kcal per day.
b. Insert a feeding tube and initiate enteral feedings.
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? Select one: a.The patient has multiple dysplastic nevi. b.The patient uses a tanning booth weekly. c.The patient is fair-skinned and has blue eyes. d.The patient's mother died of a malignant melanoma.
b. The patient uses a tanning booth weekly.
Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? Select one: a."I will wash my hands often during the day." b."I will remove my contact lenses at bedtime." c."I will not share towels with my friends or family." d."I will monitor my family for eye redness or drainage."
b."I will remove my contact lenses at bedtime."
A patient with glaucoma who has been using timolol (Timoptic) drops for several days tells the nurse that the eye drops cause eye burning and visual blurriness for a short time after administration. The best response to the patient's statement is Select one: a."Those symptoms may indicate a need for a change in dosage of the eye drops." b."The drops are uncomfortable, but it is important to use them to retain your vision." c."These are normal side effects of the drug, which should be less noticeable with time." d."Notify your health care provider so that different eye drops can be prescribed for you."
b."The drops are uncomfortable, but it is important to use them to retain your vision."
There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? Select one: a.50-yr-old with skin redness after having a chemical peel 3 days ago b.38-year old with a 7-mm nevus on the face that has recently become darker c.62-yr-old with multiple small, soft, pedunculated papules in both axillary areas d.42-yr-old with complaints of itching after using topical fluorouracil on the nose
b.38-year old with a 7-mm nevus on the face that has recently become darker
Which patient should the nurse assess first? Select one: a.A patient with burns who is complaining of level 8 (0 to 10 scale) pain b.A patient with smoke inhalation who has wheezes and altered mental status c.A patient with full-thickness leg burns who is scheduled for a dressing change d.A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr
b.A patient with smoke inhalation who has wheezes and altered mental status
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? Select one: a.Suggest an appointment with a dermatologist. b.Assess the patient for evidence of liver disease. c.Teach the patient about skin changes with aging. d.Discuss the use of sunscreen to prevent skin cancers.
b.Assess the patient for evidence of liver disease.
The nurse is developing a plan of care for an adult patient diagnosed with adult inclusion conjunctivitis (AIC) caused by Chlamydia trachomatis. Which action should be included in the plan of care? Select one: a.Applying topical corticosteroids to decrease inflammation b.Discussing the need for sexually transmitted infection testing c.Educating about the use of antiviral eyedrops to treat the infection d.Assisting with applying for community visual rehabilitation services
b.Discussing the need for sexually transmitted infection testing
A patient with an eye injury requires an ocular examination to detect the presence of a foreign body. The nurse anticipates that which drug will be used for this examination? Select one: a.Phenylephrine (Neo-Synephrine) b.Fluorescein sodium (AK-Fluor) c.Atropine sulfate (Isopto Atropine) d.Olopatadine (Patanol)
b.Fluorescein sodium (AK-Fluor)
Which prescribed medication should the nurse give first to a patient who has just been admitted to a hospital with acute angle-closure glaucoma? Select one: a.Morphine sulfate 4 mg IV b.Mannitol (Osmitrol) 100 mg IV c.Betaxolol (Betoptic) 1 drop in each eye d.Acetazolamide (Diamox) 250 mg orally
b.Mannitol (Osmitrol) 100 mg IV
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take first? Select one: a.Monitor the pulses every hour. b.Notify the health care provider. c.Elevate both legs above heart level with pillows. d.Encourage the patient to flex and extend the toes.
b.Notify the health care provider.
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? Select one: a.Ringlike rashes with red, scaly borders over the entire scalp b.Papular, wheal-like lesions with white deposits on the hair shaft c.Patchy areas of alopecia with small vesicles and excoriated areas d.Red, hivelike papules and plaques with sharply circumscribed borders
b.Papular, wheal-like lesions with white deposits on the hair shaft
Which patient arriving at the urgent care center will the nurse assess first? Select one: a.Patient with purulent left eye discharge and conjunctival inflammation b.Patient with acute right eye pain that began while using home power tools c.Patient who is complaining of intense discomfort after an insect crawled into the right ear d.Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness
b.Patient with acute right eye pain that began while using home power tools
The nurse is preparing to administer a new order for eardrops. Which is a potential contraindication to the use of many otic preparations? Select one: a.Ear canal itching b.Perforated eardrum c.Staphylococcus aureus otitis externa infection d.Escherichia coli ear infection
b.Perforated eardrum
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? Select one: a.Assess pain level. b.Place on heart monitor. c.Check potassium level. d.Assess oral temperature.
b.Place on heart monitor.
The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? Select one: a.The nurse leaves the eye shield in place. b.The nurse encourages the patient to cough. c.The nurse elevates the patient's head to 45 degrees. d.The nurse applies corticosteroid drops to the right eye.
b.The nurse encourages the patient to cough.
Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? Select one: 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.
b.The patient's oral temperature is 100.8° F (38.1° C).
While the patient's full-thickness burn wounds to the face are exposed, what nursing action prevents cross contamination? Select one: a.Use sterile gloves when removing dressings. b.Wear gown, cap, mask, and gloves during care. c.Keep the room temperature at 70° F (20° C) at all times. d.Give IV antibiotics to prevent bacterial colonization of wounds.
b.Wear gown, cap, mask, and gloves during care.
A father calls because his son has head lice. He reports that he used Kwell shampoo three times, but nothing happened." He wants to know what to do now. What will the nurse advise first? Select one: a."It sounds like you need a prescription for a second product, malathion." b."Try one of the lotion products instead." c."Be sure to use a nit comb to remove nits from the hair shafts." d."Try combing through the hair with mineral oil to loosen the lice from the hair shafts."
c."Be sure to use a nit comb to remove nits from the hair shafts."
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? Select one: a.Treatment plans include watchful waiting. b.Screening for metastasis will be important. c.Minimizing sun exposure reduces risk for future BCC. d.Low dose systemic chemotherapy is used to treat BCC.
c.Minimizing sun exposure reduces risk for future BCC.
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? Select one: a.Hematocrit of 53% b.Serum sodium of 147 mEq/L c.Serum potassium of 6.1 mEq/L d.Blood urea nitrogen of 37 mg/dL
c.Serum potassium of 6.1 mEq/L
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? Select one: a.Ensure the patient wears shoes with nonslip soles. b.Discourage using throw rugs throughout the house. c.Talk with the patient alone and ask about the bruising. d.Notify the health care provider so that radiographs can be ordered.
c.Talk with the patient alone and ask about the bruising.
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? Select one: a.Bananas b.Orange gelatin c.Vanilla milkshake d.Whole grain bagel
c.Vanilla milkshake
The nurse is teaching a patient about proper administration of eardrops. Which statements are correct? (Select all that apply.) Select one or more: a.Remove cerumen with a cotton-tipped swab before instilling the drops. b.Instill the drops while still cool from refrigeration. c.Warm the eardrops to room temperature before instillation. d.The adult patient should pull the pinna of the ear up and back. e.Insert a dry cotton ball firmly into the ear canal after instillation. f.Massage the earlobe after instillation.
c.Warm the eardrops to room temperature before instillation. d.The adult patient should pull the pinna of the ear up and back. e.Insert a dry cotton ball firmly into the ear canal after instillation.
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? Select one: a.Discuss the possibility of participating in an online support group. b.Encourage the patient to volunteer to work on community projects. c.Suggest that the patient use cosmetics to cover the psoriatic lesions. d.Ask the patient to describe the impact of psoriasis on quality of life.
d. Ask the patient to describe the impact of psoriasis on quality of life.
A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? Select one: a.The use of eye patches to reduce movement of the operative eye b.The need to wear dark glasses to protect the eyes from bright light c.The purpose of maintaining the head resting in a prescribed position d.The procedure for dressing changes when the eye dressing is saturated
d. The procedure for dressing changes when the eye dressing is saturated
A patient is admitted to the hospital for possible septicemia. He has a large pressure ulcer on his heel that is open and includes necrotic tissue. However, his prothrombin time/international normalized ratio (PT/INR) values are too high to permit surgical débridement at this time. The nurse expects that which wound-care product will be used to treat the wound? Select one: a.Cadexomer iodine (Iodosorb) b.Biafine topical emulsion c.Povidone-iodine (Betadine) d.Collagenase (Santyl)
d.Collagenase (Santyl)
To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? Select one: a.Perform tympanometry. b.Schedule otoscopic examinations. c.Administer influenza immunizations. d.Discuss exposure to amplified music.
d.Discuss exposure to amplified music.
A patient has been taking the corticosteroid dexamethasone (Decadron) but has developed bacterial conjunctivitis and has a prescription for gentamicin (Garamycin) ointment. The nurse notes that which interaction is possible if the two drugs are used together? Select one: a.The infection may become systemic. b.The gentamicin effects may become more potent. c.The corticosteroid may cause overgrowth of nonsusceptible organisms. d.Immunosuppression may make it more difficult to eliminate the eye infection.
d.Immunosuppression may make it more difficult to eliminate the eye infection.
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? Select one: a.Check skin turgor. b.Monitor daily weight. c.Assess mucous membranes. d.Measure hourly urine output.
d.Measure hourly urine output.