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Which information is most concerning to the nurse when caring for an
older
client with bilateral cataracts?
A. States having difficulty with color perception
B. Presents with opacity of the lens upon assessment
C. Complains of seeing a cobweb-type structure in
the visual field
D. Reports the need to use a magnifying glass to see
small print - ANS-C. Complains of seeing a cobweb-type structure in
the visual field
When caring for a client hospitalized with Guillain-Barré syndrome,
which
information is most important for the nurse to report to the primary
health care
provider?
A. Ascending numbness from the feet to the knees
B. Decrease in cognitive status of the client
C. Blurred vision and sensation changes
D. Persistent unilateral headache - ANS-B. Decrease in cognitive status
of the client
Rationale
A decline in cognitive status in a client is indicative of symptoms of
hypoxia and a
possible need to assist the client with mechanical ventilation. A primary
health care
, provider will need to be contacted immediately. Options A, C, and D are
findings
associated with Guillain-Barré syndrome that should also be reported
but are not as
critical as the client's hypoxic status.
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering
the medication?
A) Checking the client's blood pressure
B) checking the client's peripheral pulses
C) checking the most recent potassium level
D) checking the client's intake and output record for the last 24 hours -
ANS-A) Checking the client's blood pressure
Rationale--enalapril maleate is an angiotensin-converting enzyme (ACE)
inhibitor used to treat hypertension. One common side effect is postural
hypotension. Therefore the nurse would check the client's blood
pressure immediately before administering each dose.
A client is scheduled to undergo an upper gastrointestinal (GI) series, and
the nurse provides instructions to the client about the test. Which
statement by the client indicates a need for further instruction?
A) "The test will take about 30 minutes"
B) "I need to fast for 8 hours before the test"
C) "I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
D) "I need to take a laxative after the test is completed, because the
liquid that I'll have to drink for the test can be constipating." - ANS-C) "I
need to drink citrate of magnesia the night before the test and give myself
a Fleet enema on the morning of the test."