15. The nurse is caring for a client with a diagnosis of detached retina.

Which assessment sign would indicate that bleeding has occurred as a result of the ret inal detachment? a) b) c) d) total loss of vision a reddened conjunctiva a sudden sharp pain in the eye complaints of a burst of black spots or floaters

16. The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately? a) b) c) d) notify the physician apply ice to the affected eye irrigate the eye with cool water accompany the client to the emergency room

17. The client arrives in the emergency room with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and note s a piece of wood protruding form the eye. What is the initial nursing action? a) b) c) d) apply an eye patch perform visual acuity tests irrigate the eye with sterile saline remove the piece of wood using a sterile eye clamp

18. The client arrives in the emergency room after sustaining a chemical eye inj ury from a splash of battery acid. The initial nursing action is to: a) b) c) d) begin visual acuity testing cover the eye with a pressure patch swab the eye with antibiotic ointment irrigate the eye with sterile normal saline

19. The nurse is caring for a client after a lung lobectomy. The nurse notes flu ctuating water levels in the water-seal chamber of the client's chest tube. What action should the nurse take? A. B. C. D. Do nothing, but continue to monitor the client. Call the physician immediately. Check the chest tube for a loose connection. Add more water to the water-seal chamber

20. A client with type 2 diabetes has a hemoglobin A1C level of 8.8 after 6 mont hs of oral therapy with metformin (Glucophage). The client tells the nurse that s he often forgets to take her medication and doesn't really follow her diet. Whic h of the following is the nurse's best first response? A. B. of C. D. "If you don't get control of your blood sugar, you'll need to take insulin." "It can be hard to get used to having a disease like diabetes. What are some the things you find challenging about it?" "Uncontrolled diabetes can lead to eye problems and kidneys problems." "Many people have diabetes."

21. The nurse is teaching a client newly diagnosed with type 1 diabetes how to s elf-administer subcutaneous insulin injections. How does the nurse best evaluate the effectiveness of her teaching?

A. Have the client repeat the steps back to the nurse. B. Give the client a written test on self-administration of insulin. C. Ask the client to write out the steps for self-administration of insulin inje ctions. D. Ask the client to give a return demonstration of self-administration of insul in. 22. The nurse is writing the teaching plan for a client undergoing a radioactive iodine uptake test to study thyroid function. Which of the following instructio ns should the nurse include? A. "You need to stay at least 4 feet (1.2 m) away from other people after the te st because you'll be radioactive." B. "You need to lie very still on a stretcher that is placed in a long tube for the scan" C. "Don't take any iodine or thyroid medication before the test." D. "Schedule the bone scans before your radioactive iodine uptake test." 23. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) who is undergoing induction therapy with chemotherapeutic agents tells the nurse , "I feel so sick that I don't know if the treatment is worth completing." The n urse's best response to the patient is a. "I know you feel really ill right now, but after this therapy your disease wi ll go into a remission and you will feel normal again." b. "Induction therapy is very aggressive and causes the most side effects, so wh en this phase is completed you won't feel so ill." c. "Your type of leukemia has an 80% survival rate if aggressive therapy is star ted, so the effects of treatment will be worth it to you." d. "The chemotherapy is difficult, but it is necessary to put the disease into r emission and give you time to make choices about your life. 24. The nurse is assessing a patient with gastroesophageal reflux disease (GERD) who is experiencing increasing discomfort. Which patient statement indicates th at additional patient education about GERD is needed? a. b. c. d. "I "I "I "I take antacids between meals and at bedtime each night." quit smoking several years ago, but I still chew a lot of gum." sleep with the head of the bed elevated on 4-inch blocks." eat small meals throughout the day and have a bedtime snack.

25. A patient with recurring heartburn receives a new prescription for esomepraz ole (Nexium). In teaching the patient about this medication, the nurse explains that this drug a. . b. c. d. reduces the reflux of gastric acid by increasing the rate of gastric emptying coats and protects the lining of the stomach and esophagus from gastric acid. treats gastroesophageal reflux disease by decreasing stomach acid production. neutralizes stomach acid and provides

26. A nurse is performing an initial post op assessment on a client following up per GI surgery. The client has a NG tube to low, intermittent suction. To best a ssess the client for the presence of bowel sounds, the nurse should: A. B. C. D. place the stethoscope to the left of the umbilicus. turn off the nasogastric suction. use the bell of the stethoscope. turn the suction on the NG tube to continuous.

27. A nurse is caring for a client diagnosed with Chron's disease, who has under gone a barium enema that demonstrated the presence of strictures in the ileum. B ased on this finding, the nurse should monitor the client closely for signs of: A. B. C. D. peritonitis obstruction malaborsorption. fluid imbalance.

28. While conducting a home visit with a client who had a partial resection of t he ileum for Chron's Disease 4 weeks previously, a nurse becomes concerned when the client states: A. B. C. D. My stools float and seem to have fat in them. I have gaiend 5 pounds since I left the hospital. I am still avoiding milk products. I only have 2 formed stools per day.

29. A nurse is reviewing the history and physical of a teenager admitted to a ho spital with a diagnosis of ulcerative colitis. Based on this diagnosis, which in formation should the nurse expect to see on this client's medical record? A. B. C. D. Abdominal pain and bloody diarrhea. Weight gain and elevated blood glucose. Abdominal distention and hypoactive bowel sounds. Heartburn and regurgitation.

30. A RN overhears a LPN talking with a client who is being prepared for a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. To decrease the client's anxiety, the RN should intervene to clarify the informati on given by the LPN when the LPN is heard saying: A. B. C. al D. this surgery will prevent you from developing colon cancer. after this surgery you will no longer have ulcerative colitis. when you return from surgery you will not be able to eat solid food for sever days. you will have an ileostomy when you return from the surgery.

31. The nurse is assessing a client 24 hours following a cholecystectomy. The nu rse noted that the T tube has drained 750 mL of green-brown drainage since the s urgery. Which nursing intervention is appropriate? A. B. C. D. Clamp the T tube Irrigate the T tube Notify the physician Document the findings

CORRECT ANSWERS 1. C. the patient positioned in a lateral position with the head of the bed flat . After total laryngectomy and radical neck dissection, a patient should be plac ed in a semi-Fowler's position to decrease edema and limit tension on the suture line. 2. C = the older adults' taste buds retain their sensitivity to carbohydrates. I n addition, carbohydrates. Tend to be food items that are easy to chew. Older ad ults lose their sensitivity to sour and salty foods. Older adults may find greas

y foods harder to digest and therefore may avoid them; however, preference for g reasy foods is not related to changes in taste associated with age. 3. A = caffeinated beverages and alcohol should be avoided because they stimulat e gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need t o follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer di sease. Milk in large quantities is not recommended because it actually stimulates furth er production of gastric acids. 4. C = A low sodium diet is frequently an effective mechanism for reducing the f requency and severity of the disease episodes. About three-quarters of clients with Meniere's disease respond to treatment with a low salt diet. 5. D Tympanoplasty involves surgical reconstruction as the tympanic membrane a nd is done to re-establish middle ear function, close perforation, prevent recur rent infections. 6. A = primary cancer prevention targets healthy individuals and includes steps to avoid factors that might lead to the development of diseases. 7. D = Fatigue is a common complaint of individuals receiving medication therapy . 8. D = When a wound eviscerates, the nurse should cover the open area with steri le dressing moistened with sterile normal saline and then cover it with a dry dr essing. The surgeon should then be notified to take the client back to the operating roo m to close the incision under general anesthesia. 9. D = the symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy and urinary retention. 10. A = There are many mechanisms of action for chemotherapeutic agents, but mos t affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cell s are characterized by rapid cell division. Chemotherapy slows cell division 11. B = the nurse should notify the anesthesiologist because a serum potassium l evel of 5.8 mEq/L places the client at risk for dysrhythmias when under general anesthesia. 12. A = It is appropriate for an unlicensed assistant to mark the time of measur ement and fluid level in the collection container. 13. D = Nausea and gastrointestinal upset is a common but usually temporary side effects of Paroxetine (Paxil). Therefore, the nurse would instruct the client t o take the medication with food to minimize nausea and stomach upset. 14. B Vertigo is the most frequent complication of stapedectomy. The patient s hould move slowly to avoid triggering or worsening vertigo and should ask for as sistance with ambulation. Ringing in the ears rarely follows this surgery and sh

ould be reported to the doctor if it does. Hearing typically decreases after surrey bc of ear packing and tissue swelling, but commonly returns over the next 2-6 weeks. Usually, post-op drainage and pain are minimal Excessive drainage should be reported. 15. D Complaints of a sudden burst of black spots or floaters indicates that bl eeding has occurred as a result of the detachment. Options A, B, and C are not s igns of bleeding. 16. B Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thoroug h eye examination to rule out the presence of other eye injuries. 17. B - If the laceration is the result of a penetrating injury, an object may be note d protruding from the eye. This object must never be removed except by the ophth almologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign bod y and cause further tearing of the cornea. 18. D Emergency care following a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. In the eme rgency department, the irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. Options B and C a re not a component of initial care. 19. A Fluctuation in the water-seal chamber is a normal finding that occurs as the cli ent breathes. No action is required except for continued monitoring of the clien t. The nurse doesn't need to notify the physician. Continuous bubbling in the wa ter-seal chamber indicates an air leak in the chest tube system, such as from a loose connection in the chest tube tubing. The water-seal chamber should be fill ed initially to the 2 cm line, and no more water should be added. 20. B Acknowledging that the client is going through changes and allowing her to expre ss her concerns will help the nurse assess her needs. Hemoglobin AIC shows the a verage blood glucose levels over a 3-month period. Diabetes should maintain the AIC <7%. Lecturing, threatening and comparing the clients to others belittles th e client and discourages discussion, but the patient must be provided adequate i nformation in order to make informed decisions about self-care. 21. D Asking the client to give a return demonstration of his injection technique is t he best way to assess whether the client can perform the procedure. It also give s the nurse the opportunity to provide feedback. Asking the client to recite the steps, pass a written test, or write out the steps shows the nurse whether the client is able to recall the steps but doesn't show that he has the necessary mo tor skills or the ability to perform the procedure. 22. C

Medications such as iodine, contrast media, and antithyroid and thyroid drugs ca n affect the test results and should be withheld by the client for a week or lon ger, as directed by the physician. During a radioactive iodine uptake test, the client receives radioactive iodine by mouth or I.V. in small doses and doesn't r equire isolation. During magnetic resonance imaging--not radioactive iodine upta ke testing--a client needs to lie still inside a long tube. Any test, such as a bone scan, that requires iodine contrast media should be scheduled after the rad ioactive iodine uptake test because the iodinated contrast medium can decrease u ptake. 23. D Rationale: AML is very aggressive, and survival after diagnosis is short without treatment. Induction therapy is followed by more chemotherapy, so the nurse sho uld not tell the patient that he or she will feel normal or not so ill. The surv ival with AML is not 80%. 24. D Rationale: GERD is exacerbated by eating late at night, and the nurse should pla n to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD. 25. C Rationale: The proton pump inhibitors decrease the rate of gastric acid secretio n. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastri c emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly. 26. B 27. B 28. A 29. A 30. D 31. D