when planning care for a client newly diagnosed with open angle glaucoma the nurse identifies a priority nursing problem of visual sensoryperceptual a
Logo

Nursing Elites

HESI LPN

HESI Test Bank Medical Surgical Nursing

1. 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?

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.

2. Before selecting which medication to administer, which action should the nurse implement if a postoperative client reports incisional pain and has two prescriptions for PRN analgesia?

Correct answer: A

Rationale: When a postoperative client reports incisional pain and has two prescriptions for PRN analgesia, the nurse should first compare the client’s pain scale rating with the prescribed dosing. This action ensures that the client receives the appropriate medication based on their pain level. Determining the onset of action or asking the client to choose the medication does not guarantee that the right medication is administered according to the pain intensity. Documenting the pain report is important but should not be the first action when deciding which medication to administer.

3. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which finding should the nurse document in the EMR as a therapeutic response to the lidocaine infusion?

Correct answer: D

Rationale: The correct answer is D. Decreased frequency of ventricular tachycardia (VT) episodes indicates that the lidocaine infusion is effectively managing the ventricular tachycardia. Stabilization of BP ranges (choice A) may not directly correlate with the therapeutic response to lidocaine for VT. Cessation of chest pain (choice B) may indicate pain relief but does not specifically address the effectiveness of lidocaine for VT. Reduced heart rate (choice C) is not a direct indicator of the response to lidocaine for managing VT.

4. The healthcare provider prescribes the nonsteroidal anti-inflammatory drug (NSAID) naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, 'The pills don't seem to be working. They are not helping the pain at all.' Which factor should influence the nurse’s response?

Correct answer: D

Rationale: The correct answer is D. NSAID response can vary among individuals, and sometimes a different NSAID may be more effective for a specific client. In this case, since the current NSAID (naproxen) is not providing pain relief, it is reasonable to consider switching to another NSAID. Choice A is incorrect because there is no information provided to suggest noncompliance. Choice B is incorrect as increasing the dosage without assessing the response may lead to unnecessary side effects. Choice C is incorrect because although it may take time for NSAIDs to reach therapeutic levels, lack of pain relief after a month is a valid reason to consider changing the medication rather than waiting longer.

5. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?

Correct answer: B

Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.

Similar Questions

The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?
Which signs/symptoms would be considered classical signs of meningeal irritation?
What is the most critical initial intervention for a client who is actively seizing?
A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses