-
1. Evaluation of successful resolution of a fluid volume deficit may be demonstrated by which
- of the following?
- 1. The client demonstrates an absence of postural hypotension and tachycardia
- 2. The client adheres to prescribed dietary sodium restrictions
- 3. The client maintains weight loss
- 4. The client maintains a serum Na above 145 mEq
-
2. Ms. Stone is admitted with a serum magnesium deficit. Assessment reveals a positive
- Trousseau’s and Chvostek’s signs. Which of the following nursing diagnosis would be most
- appropriate?
- 1. High risk for injury R/T increased neuromuscular irritability
- 2. High risk for injury R/T fractures secondary to loss of calcium
- 3. Fluid volume deficit R/T dehydration
- 4. Activity intolerance R/T skeletal muscle weakness
-
3. Ms. Fair is a 77-year-old female. Her husband reports that she has had a poor appetite over
- the past two weeks, with occasional nausea and vomiting. When placed on a cardiac monitor
- various abnormal heart beats are noted. Based on this data, the nurse would suspect that Ms.
- Fair is experiencing.
- 1. Hyponatremia
- 2. Hypermagnesemia
- 3. Hypercalcemia
- 4. Hypokalemia
-
4. The nurse is caring for a thoracotomy client, one day post operative on 40% humidified
- oxygen. ABG results are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on this information,
- which of the following nursing actions would be best?
- 1. Position in high fowlers and encourage coughing, deep breathing, evaluate airway
- patency
- 2. Place in prone position and request respiratory therapy to perform postural drainage and
- percussion therapy
- 3. Call the doctor and advise him of the ABGs; anticipate increase in oxygen percentage
- 4. Administer anti-anxiety agent and assist the client with a rebreathing device to increase
- oxygen levels
-
5. It is 0600 and a client is scheduled for a cardiac catheterization at 0800. Laboratory work
- completed five days ago showed: K 3.0 mEq/L, Na 148 mEq/L, glucose 178 mg/dL. He
- complains of muscle weakness and cramps. Which nursing action should be implemented at
- this time?
- 1. Hold 0700 dose of spironolactone (Aldactone®)
- 2. Encourage eating bananas for breakfast
- 3. Call the physician to suggest a stat K level
- 4. Call for a twelve lead ECG
- Burns
-
6. A client is admitted to the ER with second and third degree burns to her anterior chest, both
- arms, and right leg. Priority information to determine at the time of admission would include
- which of the following?
- 1. Percentage of burned surface area
- 2. Amount of IV fluid necessary for fluid resuscitation
- 3. Any evidence of heat inhalation or airway problems
- 4. Circumstances surrounding the burn and contamination of the area
- 7. A family member of a client who has sustained an electrical burn states, “I don’t understand
- why he has been here a week, the burn doesn’t look that bad.” The nurse’s response would be
- based on which of the following?
- 1. Electrical burns are more prone to infections
- 2. Electrical burns are always much worse than they look on the outside
- 3. Cardiac monitoring is important since burns always affect cardiac function
- 4. Electrical burns can be dececlientive as underlying tissue is damaged
- 8. A client has severe second and third degree burns over 75 percent of his body. Which
- assessment finding indicates an early problem with shock?
- 1. Epigastric pain and seizures
- 2. Widening pulse pressure and bradycardia
- 3. Cool and clammy skin and tachypnea
- 4. Kussmaul respirations and lethargy
- 9. During a first aid class, the nurse is instructing clients on the emergency care of second
- degree burns. Which of the following interventions for second degree burns of the chest and
- arms will best prevent infection?
- 1. Wash the burn with an antiseclientic soap and water
- 2. Remove soiled clothing and wrap victim in a clean sheet
- 3. Leave blisters intact and apply an ointment
- 4. Do nothing until the victim arrives in a burn unit.
- Oncology
- 10. To promote safety in the care of a client receiving internal radiation therapy the nurse
- would:
- 1. Restrict visitors who may have an upper respiratory infection
- 2. Assign only male care givers to the client
- 3. Plan nursing activities to decrease nurse exposure
- 4. Wear a lead lined apron whenever delivering client care
- 11. Which of the following measures should the nurse take while a client has a radium
- implant
- for the treatment of uterine cancer?
- 1. Evaluate the position of the applicator every two hours
- 2. Place on a low residue diet to decrease bowel movements
- 3. Encourage the use of the bedside commode every 1-2 hours
- 4. Decrease fluid intake to decrease radiation in bladder
- 12. A client with lung cancer and bone metastasis is grimacing and states, “I am a little
- uncomfortable, may I have something for pain?” Which of the following should the nurse do
- first before administering pain medication?
- 1. Check the chart to determine last medication
- 2. Encourage client to refocus on something pleasant
- 3. Notify doctor that medication is not working
- 4. Assess the severity and location of pain
- 13. A client on chemotherapy has a WBC count of 1200 mm. Based on this data, which of the
- following nursing actions should the nurse take first?
- 1. Check temperature q4h
- 2. Monitor urine output
- 3. Assess for bleeding gums
- 4. Obtain an order for blood cultures
- 14. A client is admitted to the outclient unit in the Cancer Center for his chemotherapy. He is
- lethargic, weak, and pale. His WBC count is 3000. Which of the following nursing
- interventions would be most important for the nurse to implement?
- 1. Establish emotional support
- 2. Position for physical comfort
- 3. Maintain respiratory isolation
- 4. Hand washing prior to care
- 15. Which of the following properly stated nursing diagnoses would be a priority for a 65-yearold
- client immediately after her modified radical mastectomy and axillary dissection?
- 1. Anxiety related to the mastectomy
- 2. Skin integrity, impairment of, related to mastectomy
- 3. Alteration in comfort related to incisional pain
- 4. Self-care deficit related to dressing changes
- 16. A client had a radical mastectomy for cancer in her right breast. After she returns to your
- unit, which of the following would be the most appropriate for her?
- 1. Left side with right arm protected in a sling
- 2. Right side with right arm elevated
- 3. Semi-fowlers position with right arm elevated
- 4. Prone position with right arm elevated
- 17. A client with prostatic cancer is admitted to the hospital with neutropenia. Which signs and
- symclientoms are most important for the nurse to report to the next shift?
- 1. Arthralgia and stiffness
- 2. Vertigo and headache
- 3. General malaise and anxiety
- 4. Temperature elevation and lethargy
- 18. A 32-year-old male with acute lymphocytic leukemia (ALL) is admitted with shortness of
- breath, anemia, and tachycardia. Based on this nursing assessment, the most appropriately
- stated nursing diagnosis would be:
- 1. Altered protection, immunosuppression: Leukemia
- 2. Impaired gas exchange related to decreased RBCs
- 3. Potential for infection related to altered immune system
- 4. Potential injury to decreased platelets
- Endocrine
- 19. A client is admitted with diabetic ketoacidosis. You note his respiratory rate to be 38.
- Considering his condition you are aware that this increased rate is a result of:
- 1. An effort by the body to compensate for respiratory acidosis
- 2. An effort by the body to remove excess acid from the body
- 3. An effort by the body to supply more oxygen to the depleted tissues
- 4. An effort by the body to conserve CO2
- 20. The client is admitted with acute hypoparathyroidism. To maintain client safety, which item
- is most important to have available?
- 1. Tracheostomy set
- 2. Cardiac monitor
- 3. IV monitor
- 4. Heating pad
- 21. To evaluate for the desired response of calcium gluconate in treating acute
- hypoparathyroidism the nurse would monitor the client most closely for:
- 1. Intake and output
- 2. Confusion
- 3. Tetany
- 4. Bone deformities
- 22. Which symclientom is most important for the nurse to report to the next shift about the
- client with hyperparathyroidism?
- 1. Abdominal discomfort
- 2. Hematuria
- 3. Muscle weakness
- 4. Diaphoresis
- 23. The nurse would caution the client with hypothyroidism about avoiding:
- 1. Warm environmental temperatures
- 2. Narcotic sedatives
- 3. Increased physical exercise
- 4. Numbness and tingling of fingers
- 24. In planning care for the client with hyperthyroidism, the nurse would anticipate the client to
- require:
- 1. Extra blankets for warmth
- 2. Ophthalmic drops on a regular basis
- 3. Increased sensory stimulation
- 4. Frequent low calorie snacks
- 25. The elderly client with hyperparathyroidism should be cautioned about:
- 1. Pathological fractures
- 2. Decreasing fluid intake
- 3. Tetany and tingling of fingers
- 4. Increasing physical activity
- 26. The nurse is aware that which of the following statements made by the client indicates a
- correct understanding of steroid therapy for Addison’s Disease?
- 1. “I’ll take the medicine in the morning because if I take it at night it might keep me
- awake.”
- 2. “I’ll take the same amount from now on.”
- 3. “I’ll increase my potassium by eating more bananas.”
- 4. “I’ll be eating foods low in carbohydrates and salt.”
- 27. Which nursing action has the highest priority in caring for the client with
- hypoparathyroidism?
- 1. Develop a teaching plan
- 2. Plan measures to deal with cardiac arrhythmias
- 3. Take measures to prevent a respiratory infection
- 4. Assess laboratory results
- 28. A client is going to have a parathyroidectomy. Which of the following foods would the
- nurse discourage the client from eating?
- 1. Milk products
- 2. Green vegetables
- 3. Seafood
- 4. Poultry products
- 29. Which of the following types of foods would the nurse encourage the client with
- hypoparathyroidism to eat?
- 1. High phosphorus
- 2. High calcium
- 3. Low sodium
- 4. Low potassium
- 30. A client is admitted for a series of tests to verify the diagnosis of Cushing’s syndrome.
- Which of the following assessment findings would support this diagnosis?
- 1. Buffalo hump, hyperglycemia, and hypernatremia
- 2. Nervousness, tachycardia, and intolerance to heat
- 3. Lethargy, weight gain, and intolerance to cold
- 4. Irritability, moon face, and dry skin
- 31. One hour after receiving 7 units of regular insulin, the client presents with diaphoresis,
- pallor, and tachycardia. The priority nursing action would be:
- 1. Notify the doctor
- 2. Call the lab for a blood glucose level
- 3. Offer the client milk and crackers
- 4. Administer GlucagonÒ
- 32. A client was admitted for regulation of her insulin. She takes 15 units of HumulinÒ insulin
- at 8:00 a.m. every day. At 4:00 p.m., which of the following nursing observations would
- indicate a complication from the insulin?
- 1. Acetone odor to the breath, polyuria, and flushed skin
- 2. Irritable, tachycardia, and diaphoresis
- 3. Headache, nervousness, and polydipsia
- 4. Tenseness, tachycardia, and anorexia
- 33. A client received regular insulin, 6 units, 3 hours ago. Which of the following assessments
- would be most important to report to the next shift?
- 1. Kussmaul’s respirations and diaphoresis
- 2. Anorexia and lethargy
- 3. Diaphoresis and trembling
- 4. Headache and polyuria
- Cardiovascular
- 34. A client with sudden onset of deep vein thrombosis is started on a heparin IV drip. Which of
- the following additional orders should the nurse question?
- 1. Cold wet packs to the affected leg
- 2. Elevate foot of bed six inches
- 3. Commode privileges without weight-bearing
- 4. Elastic Stockings on unaffected leg
- 35. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg.
- Which of the following would be an appropriate nursing goal for this client?
- 1. To decrease inflammatory response in the affected extremity and prevent emboli
- formation
- 2. To increase peripheral circulation and oxygenation of affected extremity
- 3. To prepare client and family for anticipated vascular surgery on affected extremity
- 4. To prevent hypoxia associated with the development of pulmonary emboli
- 36. Which of the following signs indicate effective CPR?
- 1. Adequate capillary refill
- 2. Normal skin color
- 3. Symmetrically dilated pupils
- 4. Palpable carotid pulse
- 37. A permanent demand pacemaker set at a rate of 72 is implanted in a client for persistent
- third degree block. Which of the following nursing interventions would indicate a
- pacemaker dysfunction?
- 1. Pulse rate of 88 and irregular
- 2. Apical pulse rate regular at 68
- 3. Blood pressure of 110/80, pulse of 78
- 4. Tenderness at site of pacemaker implant
- 38. A client with an irregular pulse rate of 181 and a K level of 3.0 mEq/L has Lanoxin®
- ordered. The nurse should:
- 1. Give the digoxin since the pulse is within normal limits
- 2. Holds the digoxin since the pulse is irregular
- 3. Call the doctor to report the potassium
- 4. Hold the digoxin since toxicity occurs with high potassium levels
- 39. The nurse has administered sublingual nitroglycerin (Nitrostat®) to a client complaining of
- chest pain. Which of the following observations is most important for the nurse to report to
- the next shift?
- 1. The client indicates the need to use the bathroom
- 2. Blood pressure has decreased from 140/80 to 90/60
- 3. Respiratory rate has increased from 16 to 24
- 4. The client indicates the chest pain has subsided
- 40. A 72-year-old client has an order for digoxin (Lanoxin®) 0.25 mg PO in the morning. The
- nurse reviews the following information:
- apical pulse: 68
- respirations: 16
- plasma digoxin level: 2.2 ng/ml
- Based on this assessment, which nursing action is appropriate?
- 1. Give the medication on time
- 2. Withhold the medication, notify the physician
- 3. Administer epinephrine 1:1000 stat
- 4. Check the client’s blood pressure
- 41. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
- want to make sure you have the most up to date material so that you can pass your boards
- the first time.
- Respiratory
- 42. When obtaining a specimen from a client for sputum culture and sensitivity which of the
- following instructions would be best?
- 1. After pursed lip breathing cough into container
- 2. Upon awakening cough deeply and expectorate into container
- 3. Save all sputum for 3 days in covered container
- 4. After respiratory treatment expectorate into container
- 43. Which of the following is the most effective method for the nurse to evaluate the
- effectiveness of tracheal suctioning?
- 1. Note subjective data such as, “My breathing is much improved now.”
- 2. Note objective findings such as decreased respiratory rate and pulse
- 3. Consult with respiratory therapy to determine effectiveness
- 4. Auscultate the chest for change or clearing in adventitious breath sounds
- 44. After a bronchoscopy is completed with a client, which of the following nursing
- observations would indicate a complication?
- 1. Depressed gag reflex
- 2. Sputum streaked with blood
- 3. Tachypnea
- 4. Widening pulse pressure
- 45. The nurse is caring for a client with pneumonia. Which of the following nursing
- observations would indicate a therapeutic response to the treatment for the infection?
- 1. Oral temperature of 101ºF, increased chest pain with non-productive cough
- 2. Cough productive of thick green sputum, client state he feels tired
- 3. Respirations at 20, with no complaints of dyspnea, moderate amount of thick white
- sputum
- 4. White cell count of 10,000 mm, urine output at 40 ml/hr, decreasing amount of sputum
- 46. During the shift report, a client’s ventilator alarm is activated. Which action would the nurse
- implement first?
- 1. Notify the respiratory therapist
- 2. Check the ventilator tubing for excess fluid
- 3. Deactivate the alarm and check the spirometer
- 4. Assess the client for adequate oxygenation
- 47. The nurse is caring for a client who has a 5 year history of chronic lung disease. The nursing
- assessment reveals a severely dyspneic client, pulse at 140, respirations labored, and
- slightly cyanotic. An appropriate nursing action to relieve the client’s dyspnea would
- include:
- 1. Administer oxygen at 40% heated mist
- 2. Assist the client to cough and deep breathe
- 3. Elevate the head of the bed, low flow oxygen
- 4. Position the client prone and assess breath sounds
- 48. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
- want to make sure you have the most up to date material so that you can pass your boards
- the first time.
- 49. The nurse is caring for a client who has been immobilized for three days following a
- perineal prostatectomy. The client begins to experience sudden shortness of breath, chest
- pain, and coughing with blood-tinged sputum. Immediate nursing actions would include:
- 1. Elevate the head of the bed, begin oxygen, assess respiratory status
- 2. Assist the client to cough, if unsuccessful then perform nasotracheal suctioning
- 3. Position in supine position with legs elevated; monitor CVP closely
- 4. Administer morphine for chest pain; obtain a 12 lead ECG to evaluate cardiac status
- 50. Your client becomes extubated while being turned. He is cyanotic and has bradycardia and
- arrhythmias. Which action would be the highest priority while waiting for a physician to
- arrive?
- 1. Immediately begin CPR
- 2. Increase the IV fluids
- 3. Provide oxygen by ambuing and maintaining the airway
- 4. Prepare the medication for resuscitation
- Orthopedic
- 51. A client had a below-the-knee amputation due to problems with gangrene. During the first 2
- hours after surgery which nursing action would be most important?
- 1. Notify the doctor of a small amount of serosanguineous drainage
- 2. Elevate the stump on a pillow to decrease edema
- 3. Maintain the stump flat on the bed by placing the client in the prone position
- 4. Do passive range of motion TID to the unaffected leg
- 52. A client is admitted with a fractured right hip. The doctor writes an order for Buck’s
- traction. In planning care for a client in Buck’s traction, the nurse would:
- 1. Turn the client every two hours to the unaffected side
- 2. Maintain client in a supine position
- 3. Encourage client to use a bedside commode
- 4. Prevent foot drop by placing a foot board to the bed
- 53. Question deleted due to NCLEX® changes. We are sorry for the inconvenience, but we
- want to make sure you have the most up to date material so that you can pass your boards
- the first time.
- 54. Following hip replacement surgery, an elderly client is ordered to begin ambulation with a
- walker. In planning nursing care, which statement by the nurse will best help this client?
- 1. Sit in a low chair for ease in getting up in the walker
- 2. Make sure rubber caps are present on all 4 legs of the walker
- 3. Begin weight-bearing on the affected hip as soon as possible
- 4. Practice tying your shoes before using the walker
- 55. To prevent neurological complications for a pre-school client with a full-leg cast, the nurse
- would schedule regular checks of:
- 1. Femoral pulses
- 2. Levels of consciousness
- 3. Blood pressure readings
- 4. Sensory testing of affected foot
- 56. A teenager has had a repair of an open compound fracture of the tibia and fibula. An
- external fixation device has been applied to stabilize the fracture. Before administering pin
- site care, the nurse should check which of the following?
- 1. Correct alignment
- 2. Appearance of pin sites
- 3. Tightness of screws
- 4. Vital signs
- 57. Which nursing assessment suggests a complication of a plaster of paris cast application to
- the arm?
- 1. The client states that the wet cast feels “warm”
- 2. The client is able to move his fingers and thumb freely
- 3. The client states that his little finger feels “asleep”
- 4. The wet cast appears gray and smells slightly musty
- Renal
- 58. In planning the diet teaching for a child in the early stage of nephrotic syndrome, the nurse
- would discuss with the parents the following dietary changes:
- 1. Adequate protein intake, low sodium
- 2. Low protein, low potassium
- 3. Low potassium, low calorie
- 4. Limited protein, high carbohydrate
- 59. Which of the following clients is a likely candidate for developing acute renal failure?
- 1. A female with recent ileostomy due to ulcerative colitis
- 2. Middle age male with elevated temperature and chronic pancreatitis
- 3. Teenager in hypovolemic shock following a crushing injury to the chest
- 4. Child with compound fracture of right femur and massive laceration to left arm
- 60. A client is experiencing severe pain from renal calculi. Which of the following is a priority
- in the nursing care plan?
- 1. Administer pain medication as often as needed according to doctor’s orders
- 2. Encourage fluid intake to help flush the stone through
- 3. Assist the client to ambulate to promote draining the bladder
- 4. Irrigate the bladder to maintain urinary patency
- 61. In order to maintain asepsis, the client on home peritoneal dialysis should be taught to:
- 1. Drink only distilled water
- 2. Cap the Tenchkoff catheter when not in use
- 3. Boil the dialysate one hour prior to a pass
- 4. Clean the arteriovenous fistula with hydrogen peroxide daily
- 62. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values
- include BUN 25, K 5.0. Which nutrients should be restricted in this client’s diet?
- 1. Protein
- 2. Fats
- 3. Carbohydrates
- 4. Magnesium
- Gastrointestinal
- 63. A client had surgery for cancer of the colon and a colostomy was performed. Prior to
- discharge, the client states that he will no longer be able to swim. The nurse’s response
- would be based on which of the following?
- 1. Swimming is not recommended, the client should begin looking for other areas of interest
- 2. Swimming is not restricted if the client wears a water tight dressing over the stoma
- 3. The client cannot go into water that is over the stoma area, he can only go into water up
- to the stoma area
- 4. There are no restrictions on the activity of a client with a colostomy, all previous
- activities may be resumed
- 64. A client who is fourth day post-op appendectomy complains of severe abdominal pain.
- During the initial assessment he states, “I have had two almost black stools today.” Which
- nursing action is most important?
- 1. Start an IV with D5W at 125 ml/hr
- 2. Insert a nasogastric tube
- 3. Notify the doctor
- 4. Obtain a specimen
- 65. The nurse is caring for a client with a perforated bowel secondary to a bowel obstruction. At
- the time the diagnosis is made, which of the following would be a priority in the nursing
- care plan?
- 1. Maintain the client in a supine position
- 2. Notify the client’s next of kin
- 3. Prepare the client for emergency surgery
- 4. Remove the nasogastric tube
- 66. A nursing assessment of a client with a hiatal hernia is most likely to reveal?
- 1. A bulge in the lower right quadrant
- 2. Pain at the umbilicus radiating down into the groin
- 3. Burning sensation in mid-epigastric area each day before lunch
- 4. Awakening at night with heartburn
- 67. The nurse is caring for a client postoperative ileostomy. Which of the following nursing
- observations would relate to a postoperative complication?
- 1. The ileostomy does not require daily irrigations to maintain function
- 2. The stoma appears tight and there is a decreased amount of stool
- 3. An impaction appears to be forming in the distal anal area
- 4. A weight gain of 5 pounds related to increased fluid retention
- Neurological
- 68. The client has been lethargic, but responding to verbal commands. The nurse now assesses
- that the client is responding by withdrawing to noxious stimuli. The most appropriate
- nursing action would be:
- 1. Plan on reassessing the client in one hour
- 2. Notify the doctor that the client is deteriorating
- 3. Place the client in Trendelenburg position
- 4. Call the family and tell them the client is improving
- 69. The nurse enters the room and discovers the client has right sided paralysis, and unequal
- pupils. The most appropriate next step for the nurse is to:
- 1. Call the doctor
- 2. Assess the respiratory status
- 3. Determine the level of consciousness
- 4. Perform a complete neurological evaluation
- 70. A client is one week post cerebrovascular accident. The nurse notes the client does not
- respond readily to movement or objects in peripheral fields. Based on this nursing
- assessment, an appropriate nursing diagnosis is:
- 1. Impaired adjustment
- 2. Ineffective individual coping
- 3. Sensor-perceclientual alteration
- 4. Self-care deficit
- 71. The client is transferred to the Neuro Unit after developing right sided paralysis and aphasia.
- Which of the following should be included in the nursing care plan in order to promote
- communication with the client?
- 1. Encourage client to shake head in response to questions
- 2. Speak in a loud voice during interactions
- 3. Speak using phrases and short sentences
- 4. Encourage the use of radio to stimulate the client.
- 72. What would be the most appropriate next action for the nurse to take after noting the sudden
- appearance of a fixed and dilated pupil in the neuro client?
- 1. Re-assess in 5 minutes
- 2. Check client’s visual acuity
- 3. Lower the head of the client’s bed
- 4. Call the doctor
- 73. Which instruction would be included in planning care for a client with signs of increased
- intracranial pressure?
- 1. Encourage coughing and deep-breathing to prevent pneumonia
- 2. Suction airway every 2 hours to remove secretions
- 3. Position the client in the prone position to promote venous return
- 4. Determine cough reflex and ability to swallow prior to administering PO fluids.
- 74. A client with a closed head injury begins to vomit. Which assessment is the most important
- for the nurse to report when calling the physician?
- 1. Increasing lethargy
- 2. Heart rate of 80
- 3. Sodium level of 145
- 4. Presence of facial symmetry
- 75. The nurse is observing a client for complications following a craniotomy. The client begins
- complaining of thirst and fatigue. Which nursing observation is most important to report to
- the physician?
- 1. Specific gravity of urine is increased, urine is foul smelling
- 2. Fluid intake over past 24 hours has been 3000 ml
- 3. Urine output in excess of 4000 ml in 24 hours
- 4. Presence of diarrhea and excoriation of anal area
- EENT
- 76. A client with glaucoma has experienced severe restriction of peripheral vision. He asks the
- nurse if his vision will get better. The nurse’s best response would be based on which of the
- following?
- 1. If he maintains his medications and reduces the pressure, his vision will improve
- 2. The current damage to vision is permanent, maintaining his eye drops will prevent
- further damage
- 1. After the acute episode, surgery will be scheduled to remove his lens
- which will
- increase vision
- 4. After the pressure is stabilized, the doctor will reevaluate his vision and prescribe
- glasses to correct his vision
- 77. An adult male client complains of loss of hearing while irrigating his ear to remove cerumen
- for better observation of the tympanic membrane. The client comments that he is getting
- dizzy. The nurse would stop the procedure and:
- 1. Notify the doctor immediately
- 2. Monitor for changes in intracranial pressure
- 3. Warm the irrigant and resume the procedure
- 4. Explore the canal with a cotton applicator
- 78. The nurse is caring for a client who has just returned to his room after having a scleral
- buckling procedure done to repair his detached retina. Which of the following is an
- important nursing action on the operative day?
- 1. Remove reading material to decrease eye strain
- 2. Closely assess for presence of nausea and prevent vomiting
- 3. Assess color of drainage from affected eye
- 4. Maintain sterility for q3h saline eye irrigations
- 79. A client has a cataract removed from his left eye. Which of the following is an important
- nursing intervention in the immediate postoperative period?
- 1. Position on right side with head slightly elevated
- 2. Place client on his left side to protect eye
- 3. Perform sensory neuro checks every 2 hours
- 4. Maintain complete bed rest for the first 48 hours
- 80. The nurse is caring for a client with Meniere’s syndrome. The nurse stands directly in front
- of the client when speaking. Which of the following best describes the rationale for the
- nurse’s position?
- 1. This enables the client to read the nurse’s lips
- 2. The client does not have to turn her head to see the nurse
- 3. The nurse will have the client’s undivided attention
- 4. There is a decrease in the client’s peripheral visual field
- Blood
- 81. A client is 2 days postoperative aortic aneurysm resection. A complete blood count reveals a
- decreased red blood cell count. The nursing assessment is most likely to reveal which of the
- following?
- 1. Fatigue, pallor, and exertional dyspnea
- 2. Nausea, vomiting, and diarrhea
- 3. Vertigo, dizziness and shortness of breath
- 4. Malaise, flushing, and tachycardia
- 82. A client who is receiving a blood transfusion is experiencing a hemolytic reaction. The
- nurse would anticipate which of the following assessment findings to validate this reaction?
- 1. Hypotension, backache, low back pain, fever
- 2. Wet breath sounds, severe shortness of breath
- 3. Chills and fever occurring about an hour after infusion started
- 4. Urticaria, itching, respiratory distress
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