Nursing Elites

1. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

2. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?

• A. Limited eye movement.
• B. Decreased peripheral vision.
• C. Blurred distance vision.
• D. Photosensitivity.

Correct answer: B

Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.

3. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

• A. Drowsiness
• B. Gingival hyperplasia
• C. Weight gain
• D. Blurred vision

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

4. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

• A. Risk for infection related to thrombolysis.
• B. Risk for fluid volume deficit related to thrombolysis.
• C. Risk for impaired skin integrity related to thrombolysis.
• D. Risk for injury related to effects of thrombolysis.

Correct answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?

• A. Weakness and fatigue
• B. Intestinal cramping
• C. Weight loss
• D. Jaundiced sclera

Correct answer: D

Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.

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