RATIONALE

7. The nurse is giving home care instructions to a client who just had a cataract removed and an
intraocular lens implanted. What should the nurse tell the client?

a. Don't sleep on the operated side.

c. Aspirin may be taken for mild pain.

b. Wear the eye shield continuously for 2 weeks.

d. Straining during bowel movements is allowed.

ANSWER: A Postoperative cataract clients should avoid sleeping on the operated side as well as lifting
heavy objects or straining, all of which could cause bleeding in the eye.

Option C - Aspirin, due to its anticoagulant properties, should be avoided for the same reason.

Option B - An eye shield is worn continuously for the first 24 hours postoperatively.

Option D - Straining during a bowel movement should be avoided because it increases intraocular
pressure.

10. A client is being admitted to the post-anesthesia recovery area following lens removal and
replacement in the left eye for a cataract. The nurse places the client into which of the following most
appropriate positions?

1. On the left side with the head of bed elevated 30 degrees

2. On the right side with the head of bed elevated 30 degrees

3. Supine with the head of bed flat

4. Upright with the head and neck turned to the right

Explanation 2

Following eye surgery, the head of bed should be elevated 30 to 45 degrees and the client should lie on
back or unaffected side to reduce intraocular pressure. Small pillows may be used at the sides of the
head to immobilize the head when lying on the back. When looking at positioning questions, it is
important to consider positioning on the unaffected side.
13. A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a
corticosteroid ointment, ½" in the lower conjunctival sac four times a day as directed. The client reports
a headache and blurred vision. The nurse suspects that these symptoms represent:

a. common adverse reactions to corticosteroid therapy.

c. incorrect ointment application.

b. expected drug effects that should diminish over time.

d. increased intraocular pressure (IOP).

ANSWER: D Headache and blurred vision are symptoms of increased IOP, such as from glaucoma.
Ophthalmic corticosteroidsmay trigger an episode of acute glaucoma in susceptible clients. Although the
effects of some drugs may diminishwith continued use, this doesn't happen with ophthalmic
corticosteroids. Incorrect ointment application doesn'tcause headache or blurred vision.

16. What should the nurse do when administering pilocarpine (Pilocar)?

A. Apply pressure on the inner canthus to prevent systemic absorption.

B. Administer at bedtime to prevent night blindness.

C. Apply pressure on the outer canthus to prevent adverse reactions.

D. Flush the client's eye with normal saline solution to prevent burning.

RATIONALES: When administering pilocarpine, the nurse should apply pressure on the inner canthus to
prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus
doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with
normal saline solution after administering pilocarpine is contraindicated because it will wash the drug
out of the eye, rendering treatment ineffective.

NURSING PROCESS STEP: Implementation

CLIENT NEEDS CATEGORY: Physiological integrity

CLIENT NEEDS SUBCATEGORY: Pharmacological therapies

COGNITIVE LEVEL: Application

17. After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders
pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach
the client or a family member to administer the drug by
instilling one drop of pilocarpine 0.25% into both eyes four times daily.

The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, "OU" signifies
both eyes, and "q.i.d." means four times per day. Therefore, one drop of pilocarpine 0.25% should be
instilled into both eyes four times daily.

23. A male client is color blind. The nurse understands that this client has a problem with:

A. Rods.

B. Cones.

C. Lens.

D. Aqueous humor.

Correct Answer: B. Cones.

Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of
cones are absent or defective, color blindness occurs. Very few individuals are truly color blind, but
instead, see a disrupted range of colors. The most common forms are protanopia and deuteranopia,
conditions arising from loss of function of one of the cones, leading to dichromic vision.

Option A: Rods are sensitive to low levels of illumination but can’t discriminate color. Rods are the cells
primarily responsible for scotopic vision, or low-light vision. Rods are the more abundant cell-type of the
retina and reach their maximum density approximately 15 to 20 degrees from the fovea, a small
depression in the retina of the eye where visual acuity is highest. There are approximately 90 million rod
cells in the human retina.

Option C: The lens is responsible for focusing images. The lens is the adjustable component of the
refractive system: its shape is altered by the contraction or relaxation of the ciliary muscle to focus on
objects that are near or far.

Option D: Aqueous humor is a clear watery fluid and isn’t involved in color perception. Aqueous humor
is a low viscosity fluid secreted from plasma components by the ciliary body into the posterior chamber
of the eye. The humor then travels to the anterior chamber and proceeds to drain into the systemic
cardiovascular circulation by an incompletely understood mechanism. Aqueous humor circulation forms
the basis of intraocular pressure (IOP), which is associated with glaucoma; this is how the synthesis,
circulation, and drainage of aqueous humor become clinically significant.
29. A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

A. Place the client on his back, remove dangerous objects, and insert a bite block.

B. Place the client on his side, remove dangerous objects, and insert a bite block.

C. Place the client on his back, remove dangerous objects, and hold down his arms.

D. Place the client on his side, remove dangerous objects, and protect his head.

Correct Answer: D. Place the client on his side, remove dangerous objects, and protect his head.

During the active seizure phase, initiate precautions by placing the client on his side, removing
dangerous objects, and protecting his head from injury.

Option A: Do not insert anything on a client’s mouth during an active seizure because it may damage the
teeth. Placing the client on his back may cause obstruction of the airway.

Option B: A bite block should never be inserted during the active seizure phase. Insertion can break the
teeth and lead to aspiration.

Option C: The client should be placed in a side-lying position to facilitate drainage of secretions and
prevent aspiration.

32. The physician prescribes diazepam (Valium), 10 mg I.V., for a client experiencing status epilepticus.
Which statement about I.V. diazepam is true?

It should be administered no faster than 5 mg/minute in an adult.

Rationale: To prevent adverse reactions, which are common, I.V. diazepam should be administered no
faster than 5 mg/minute in an adult and should be given over at least 3 minutes in children. Diazepam
shouldn't be mixed with other drugs in an infusion because of the high risk of incompatibility. To help
prevent extravasation, the nurse should avoid administering diazepam in a small vein. I.V. diazepam may
cause cardiorespiratory depression; to detect this adverse reaction, the nurse should monitor the
client's vital signs carefully during administration

34. Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

a. Imbalanced nutrition: Less than body requirements

c. Impaired urinary elimination

b. Ineffective airway clearance

d. Risk for injury

Answer: B

Rationale:

In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the
client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also,
excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing
diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are
appropriate, they aren’t immediately life-threatening.

40. The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce
fatigue, the nurse should tell the client to:

a. take a hot bath.

b. rest in an air-conditioned room

c. increase the dose of muscle relaxants.

d. avoid naps during the day

Answer B. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body
temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should
be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants,
prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and
naps can relieve fatigue. Other measures to reduce fatigue in the client with multiple sclerosis include
treating depression, using occupational therapy to learn energy conservation techniques, and reducing
spasticity.

46. A client with gout is encouraged to increase fluid intake. Which of the following statements best
explains why increased fluids are encouraged for gout? *

A.Fluids decrease inflammation.

B.Fluids increase calcium absorption.

C.Fluids promote the excretion of uric acid.

D.Fluids provide a cushion for weakened bones

Answer: C. Fluids promote the excretion of uric acid.

With gout, fluids promote the excretion of uric acid. Fluids don't decrease inflammation, increase
calcium absorption, or provide a cushion for weakened bones.

59. Use of which of the following articles or types of clothing would help a client with osteoarthritis
perform activities of daily living adequately?

Velcro clothing, slip-on shoes, and rubber grippers make it easier for the client to dress and grip objects.
Zippers, ties, and buttons may be difficult for the client to use.

62. The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse
determines that the client understands the recommended changes if the client verbalizes the intention
to increase intake of which foods? Select all that apply.

1. Fish

2. Yogurt

3. Potatoes

4. Chicken

5. White bread

6. Cottage cheese

2. Yogurt

6. Cottage cheese

Rationale:

Osteoporosis is a chronic metabolic disease in which there is bone loss resulting in decreased bone
density and increased risk for fracture. Calcium intake is important to minimize the risk of osteoporosis.
The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses.
Calcium also may be added to certain products, such as orange juice, which are then advertised as being
"fortified" with calcium. Calcium supplements are also recommended to minimize the risk of
osteoporosis. Fish, potatoes, chicken, and white bread are foods that are not high in calcium.

63. The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse
should include information about which major complication:

A. Bone fracture

B. Loss of estrogen

C. Negative calcium balance

D. Dowager’s hump

Correct Answer: A. Bone fracture

Bone fracture is a major complication of osteoporosis that results when a loss of calcium and phosphate
increases the fragility of bones.

Option B: Estrogen deficiencies result from menopause and not osteoporosis.

Option C: Calcium and vitamin D supplements may be used to support normal bone metabolism, But a
negative calcium balance isn’t a complication of osteoporosis.

Option D: Dowager’s hump results from bone fractures. It develops when repeated vertebral fractures
increase spinal curvature

65. The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of
developing this disorder?

a. A 25-year-old woman who runs

b. A 36-year-old man who has asthma

c. A 70-year-old man who consumes excess alcohol

d. A sedentary 65-year-old woman who smokes cigarettes

Correct answer: D
Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-
calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of
corticosteroids, anticonvulsants, and/or furosemide also increases the risk

67. A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of
heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the
following items from the diet? A-Lean Beef B-Air Pop Corn

C-Hot Chocolate D-Raw Vegetables

Correct: C

Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes
heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into
the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure
include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein
and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be
acceptable.

68. The client attends two sessions with the dietitian to learn about diet modifications to minimize
gastroesophageal reflux. The teaching would be considered successful if the client says that she will
decrease her intake of which of the following foods?

1. Fats.

2. High-sodium foods.

3. Carbohydrates.

4. High-calcium foods.

1.

Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity
contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss.
Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux.

73. The client with a duodenal ulcer may exhibit which of the following findings during an assessment?

A. Hematemesis

B. Malnourishment
 C. Melena

D. Pain with eating

Correct Answer: C. Melena

The client with a duodenal ulcer may have bleeding at the ulcer site, which shows up as melena (black
tarry stool). Duodenal ulcers occur when there is a disruption to the surface of the mucosa of the
duodenum. These ulcers are part of peptic ulcer disease, which involves the stomach and first part of
the duodenum. The other findings are consistent with a gastric ulcer.

Option A: Patients who initially present with ulcer-related complications may present with symptoms
suggestive of upper GI bleed, including melena, hematemesis, elevated BUN, and anemia of varying
degrees in severity with associated fatigue. Patients who present with more alarming symptoms such as
anemia, melena, or hematemesis, which may represent perforation or bleeding, will likely require more
invasive forms of evaluation.

Option B: The presentation of patients with symptoms consistent with dyspepsia or peptic ulcer disease,
and most specifically, duodenal ulcers, can vary highly depending on the degree of disease progression
and time when a patient seeks treatment. Other common signs and symptoms include epigastric
abdominal pain, bloating, nausea and vomiting, and weight gain due to improved symptoms post meals.

Option D: Overall, dyspepsia is the most common symptom for patients who do experience symptoms.
The location of the disease can also be differentiated based on symptoms. The pain associated with
duodenal ulcers improves after meals, while the pain associated with gastric ulcers generally intensifies
after meals.

78. To reduce the risk of dumping syndrome, the nurse should teach the client to do which of the
following?

1. Sit upright for 30 minutes after meals.

2. Drink liquids with meals, avoiding caffeine.

3. Avoid milk and other dairy products.

4. Decrease the carbohydrate content of meals.

4.
Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because
it is digested more slowly.

Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus.

Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

81. A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed
respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains
the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels.

Explanation:

In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the
ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't
capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels
depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal
clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia
aren't as directly related to the client's level of consciousness.

85. The nurse is doing discharge teaching for a client who has cirrhosis and ascites. Which of the
following foods used by the client as snacks should the nurse instruct the client to avoid?

1. Whole wheat bread

2. Cookies

3. Potato chips

4. Hard candy

Explanation

A low-sodium diet is recommended for clients that have cirrhosis and ascites. Potato chips are high in
sodium. Cookies and hard candy are high in sugar, while bread is high in complex carbohydrates. Recall
that potato chips would rarely be a recommended snack.
91. A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To
correct this acute diabetic emergency, which measure should the health care team take first?

Initiate fluid replacement therapy.

The health care team first initiates fluid replacement therapy to prevent or treat circulatory collapse
caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client
must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't
circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement
therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the
client's condition must first be stabilized to prevent life-threatening complications.

97. A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse
hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always
possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on
hand?

1. 50% dextrose

2. Epinephrine

3. Glucagon

4. Hydrocortisone

Correct response:

Glucagon

Explanation:

During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to

raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a
treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be
administered I.V. by a skilled health care professional. Hydrocortisone takes a relatively long time to
raise the blood glucose level and therefore isn't effective in reversing hypoglycemia.

98. A client with a serum glucose level of 618 mg/dl (34.33 mmol/L) is admitted to the facility. The client
is awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6° F (38.1°
C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment
findings, which nursing diagnosis takes highest priority?

1. Deficient fluid volume related to osmotic diuresis

2. Ineffective thermoregulation related to dehydration

3. Imbalanced nutrition: Less than body requirements related to insulin deficiency

4. Decreased cardiac output related to elevated heart rate

Correct response:

Deficient fluid volume related to osmotic diuresis

Explanation:

A serum glucose level of 618 mg/dl (34.33 mmol/L) indicates hyperglycemia, which causes polyuria and
fluid volume deficit, making Deficient fluid volume related to osmotic diuresis the highest priority. In this
client, tachycardia is more likely to result from fluid volume deficit than from decreased cardiac output
because the client's blood pressure is normal. Although the client's serum glucose is elevated, food isn't
a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore,
a diagnosis of Imbalanced nutrition: Less than body requirements isn't appropriate. A temperature of
100.6° F (38.1° C) isn't life-threatening, eliminating Ineffective thermoregulation as the top priority.

100. The physician prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a male client with type
2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and
exercise. Which medication instruction should the nurse provide?

A “Be sure to take glipizide 30 minutes before meals.”

B “Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked
monthly.”

C “You won’t need to check your blood glucose level after you start taking glipizide.”

D “Take glipizide after a meal to prevent heartburn.”

Explanation: The client should take glipizide twice a day, 30 minutes before a meal, because food
decreases its absorption. The drug doesn’t cause hyponatremia and therefore doesn’t necessitate
monthly serum sodium measurement. The client must continue to monitor the blood glucose level
during glipizide therapy.
67. An essential aspect of the plan of care for the client after cataract removal surgery would be to:

a. Increase cardiac output

c. Maintain a darkened environment

b. Prevent fluid volume excess

d. Promote safety at home

ANSWER: D Promoting safety is a priority goal for this client. The client's vision will not be clear, and she
may need to wear an eye patch after surgery. Orienting the client to the physical environment, assisting
her during ambulation, and following other safety precautions to reduce the risk of injury are required.

Option A - Cardiac output has no relationship to cataract surgery.

Option B - Fluid volume excess has no relationship to cataract surgery.

Option C - Maintaining a darkened environment is neither necessary nor safe.

68. After cataract removal surgery, the nurse teaches the client about activities that she can do at home.
Which of the following activities would be contraindicated?

a. Walking down the hall unassisted.

c. Performing isometric exercises.

b. Lying in bed on the non-operative side.

d. Bending over the sink to wash her hair.

ANSWER: D. Bending over the sink to wash hair is contraindicated after cataract surgery because it
increases intraocularpressure. The client should be taught to tilt her head backward slightly when
washing her hair.

Option A - Walking is not contraindicated.

Option B - Lying in bed on the nonoperative side is not contraindicated.

Option C - Performing isometric exercises is not contraindicated.

33. The nurse notes a slight cloudy appearance to the lens of a 64-years-old client’s eyes. Which of the
following symptoms should the nurse question the client about?

a. Sense of curtain feeling over vision

c. Slight but constant eye pain

b. Blurring of vision

d. Double vision

ANSWER: B A cloudy-appearing lens is characteristic of cataract development. Early symptoms of

cataract formation include blurred vision and loss of ability to see colors. A sense of a curtain falling
across the field of vision characterizes detached retina. Eye pain and double vision are not symptoms
associated with cataracts.

34. Before giving a beta-adrenergic blocker glaucoma agent, the nurse would notify the physician if the
client discloses a history of what condition?

a. Bradycardia

b. Tachycardia

c. Hypertension

d. Rheumatoid arthritis

ANSWER: A All beta adrenergic blockers are contraindicated in clients with bradycardia. Alpha
adrenergic agents can cause tachycardia and hypertension. Carbonic anhydrase inhibitors should not be
given to clients with rheumatoidarthritis who are taking high doses of aspirin.

35. The nurse is reviewing the client’s understanding of post-operative stapedectomy instructions that
the nurse gave several days ago. Which comment made by the client would concern the nurse the most?

a. “I have been coughing a lot with my mouth open”

b. “I am going to take swimming lessons in a couple of mouths”

c. “I have to take a long overseas flight in a couple of weeks”

d. “I can’t wait to get back to my weightlifting classes at the gym”

ANSWER: D Heavy lifting should be strictly avoided for at least 3 weeks. Water in the ear and air travel
should be avoided for at least a week. Coughing and sneezing should be performed with the mouth
open to prevent increased pressure.