a patient with glaucoma is verbalizing his daily medication routine to the nurse he states he has two different eye drop medications both every twelve

NCLEX-RN

NCLEX RN Exam Review Answers

1. A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eye drop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse's best response?

A. ''You should wait more than 1 minute between different medications.''
B. ''Your routine is very good! Can you demonstrate it for me?''
C. ''It is actually not the best practice to close your eyes after instilling eye drops.''
D. ''You should actually be pressing your finger in the other corner of the eye.''

Correct answer: A

Rationale: It is recommended to wait 10-15 minutes between different eye drop medications to give them time to absorb and avoid one medication washing another one out. Choice A is the correct response as the patient should wait more than 1 minute between administering different eye drop medications. Choice B is incorrect as the routine described by the patient needs improvement. Choice C is inaccurate as closing the eyes after instilling eye drops is a best practice to ensure proper absorption. Choice D is incorrect as pressing the finger to the corner of the eye nearest the nose is the correct technique.

2. The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?

A. We will encourage our child to cough every few hours on a daily basis.
B. We will make sure that our child participates in physical activity every day.
C. We will provide comfort measures to reduce any crying periods by our child.
D. We will be sure to give our child a Fleet enema every day to prevent constipation.

Correct answer: C

Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.

3. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:

A. Instruct the client to maintain a regular diet the day prior to the examination
B. Restrict the client's fluid intake 4 hours prior to the examination
C. Administer a laxative to the client the evening before the examination
D. Inform the client that only 1 x-ray of his abdomen is necessary

Correct answer: C

Rationale: Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (Choice A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (Choice B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (Choice D) is not relevant to the preparation process for an IVP.

4. The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

A. The nail beds.
B. The skin in the sacral area.
C. The skin in the abdominal area.
D. The membranes in the ear canal.

Correct answer: A

Rationale: Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

5. Which of the following is TRUE about shock?

A. A patient with severe shock does not always have an abnormally low blood pressure.
B. Confusion and deteriorating mentation are indicative of hypotensive shock.
C. Patients with compensated shock may not be able to maintain a normal blood pressure.
D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.