Nursing Elites

1. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

• A. Maintain prescribed eye drop regimen
• B. Avoid frequent eye pressure measurements
• C. Wear prescription glasses
• D. Eat a diet high in carotene

Correct answer: A

Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.

2. A patient has been taking spironolactone (Aldactone) to treat heart failure. The nurse will monitor for

• A. hyperkalemia.
• B. hypermagnesemia.
• C. hypocalcemia.
• D. hypoglycemia.

Correct answer: A

Rationale: The correct answer is A: hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in heart failure management. One of the major side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the blood. Monitoring for hyperkalemia is crucial as it can lead to serious cardiac arrhythmias. Choices B, C, and D are incorrect. Hypermagnesemia (choice B) is not typically associated with spironolactone use. Hypocalcemia (choice C) and hypoglycemia (choice D) are also not directly linked to the use of spironolactone in heart failure treatment.

3. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

• A. Notify social services immediately if suspected elderly abuse is present.
• B. Discuss the need for mental health counseling with the daughter.
• C. Explain to the client the importance of taking better care of herself.
• D. Collect further data to determine whether self-neglect is occurring.

Correct answer: D

Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.

4. The healthcare provider is assessing a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings would indicate a complication of the treatment?

• A. Clear dialysate outflow.
• B. Cloudy dialysate outflow.
• C. Decreased urine output.
• D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is a sign of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Peritonitis, an infection of the peritoneum, the lining of the abdominal cavity, can lead to severe complications if not treated promptly. Clear dialysate outflow is an expected finding in peritoneal dialysis, indicating proper functioning of the process. Decreased urine output is common in clients with renal failure due to impaired kidney function. Increased blood pressure may be present in renal failure but is not a direct complication of peritoneal dialysis.

5. A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?

• A. Avoid high carbohydrate foods.
• B. Decrease intake of fat-soluble vitamins.
• C. Decrease caloric intake.
• D. Restrict salt and fluid intake.

Correct answer: D

Rationale: The correct answer is to restrict salt and fluid intake. In clients with cirrhosis presenting with pedal edema and ascites, excessive fluid retention occurs, necessitating the restriction of salt and fluid to alleviate these symptoms. Choice A, avoiding high carbohydrate foods, is not the priority in this situation. Decreasing intake of fat-soluble vitamins (Choice B) is not specifically indicated for managing edema and ascites in cirrhosis. While maintaining an appropriate caloric intake is important, decreasing caloric intake (Choice C) is not the primary focus when addressing fluid retention in cirrhosis.

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