What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma?

Medical and Surgical Nursing (NCLEX Exams)

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1.) A client is receiving NPH insulin 20 units subq at 7:00 AM daily, at 3 PM how would the nurse finds if the client were having a hypoglycemic reaction?

1. Feel the client and bed for dampness
2. Observe client kussmaul respirations
3. Smell client’s breathe for acetone odor
4. Check client’s pupils for dilation

2.) Postoperative thyroidectomy nursing care includes which measures?

1. Have the client speak every 5-10 mins if hoarseness is present
2. Provide a low calcium diet to prevent hypercalcemia
3. Check the dressing all the back of the neck for bleeding
4. Apply a soft cervical collar to restrict neck movement

3.) What would the nurse note as typical findings on the assessment of a client with acute pancreatitis?

1. Steatorrhea, abd. Pain, fever
2. Fever, hypoglycemia, DHN
3. Melena, persistent vomiting, hyperactive bowel sounds
4. Hypoactive bowel sounds, decreased amylase and lipase levels

4.) A client is found to be comatose and hypoglycemic with a blood suger level 50 mg/dl. What nursing action is implemented first?

1. Infuse 1000 ml of D5W over a 12-hour period
2. Administer 50% glucose IV
3. Check the client’s urine for the presence of sugar and acetone
4. Encourage the client to drink orange juice with added sugar

5.) Which medication will the nurse have available for the emergency treatment of tetany in the client who has had a thyroidectomy?

1. Calcium chloride
2. Potassium chloride
3. Magnesium sulfate
4. Sodium bicarbonate

6.) What is the primary action of insulin in the body?

1. Enhances the transport of glucose across cell walls
2. Aids in the process of gluconeogenesis
3. Stimulates the pancreatic beta cells
4. Decreases the intestinal absorption of glucose

7.) What will the nurse teach the diabetic client regarding exercise in his /her treatment program?

1. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin
2. With an increase in activity the body will utilize more carbohydrates; therefore more insulin will be required.
3. The increase in activity results in an increase in the utilization of insulin; therefore the client should decrease his/her carbohydrate intake
4. Exercise will improve pancreatic circulation and stimulate the islet of Langerhans to increase the production of intrinsic insulin

8.) The nurse is caring for a client who has exophthalmos associated with her thyroid disease. What is the cause of exophthalmos?

1. Fluid edema in the retro-orbital tissues which force the eyes to protrude
2. Impaired vision, which causes the client to squint in order to see
3. Increased eye lubrication, which makes the client blink less
4. Decrease in extraocular eye movements, which results in the “thyroid stare.”

9.) What is characteristic symptom of hypoglycemia that should alert nurse to an early insulin reaction?

1. Diaphoresis
2. Drowsiness
3. Severe thirst
4. Coma

10.) A client is scheduled for routine glycosylated hemoglobin (HbA1c) test. What is important for the nurse to tell the client before this test?

1. Drink only water after midnight and come to the clinic early in the morning
2. Eat a normal breakfast and be at the clinic 2 hours because of the multiple blood draws
3. Expect to be at the clinic for several hours because of the multiple blood draws
4. Come to the clinic at the earliest convenience to have blood drawn

11.) A client has been inhalation vasopressin therapy. What will the nurse evaluate to determine the therapeutic response to this medication?

1. Urine specific gravity
2. Blood glucose
3. Vital signs
4. Oxygen saturation levels

12.) A client with diagnosis of type 2 diabetes has been ordered a course of prednisone for her severe arthritic pain. An expected change that requires close monitoring by the nurse is;

1. Increased blood glucose level
2. Increased platelet aggregation
3. Increased ceatinine clearance
4. Increased ketone level in urine

13.) The nurse performing an assessment on a client who has been receiving long-term steroid therapy would expect to find:

1. Jaundice
2. Flank pain
3. Bulging eyes
4. Central obesity

14.) A diabetic client receives a combination of regular and NPH insulin at 0700 hours. The nurse teaches the client to be alert for signs of hypoglycemia at

1. 1200 and 1300 hours
2. 1100 and 1700 hours
3. 1000 and 2200 hours
4. 0800 and 1100 hours

15.) It is important for the nurse to teach the client that metformin (Glcucophage):

1. May cause nocturia
2. Should be taken at night
3. Should be taken with meals
4. May increase the effects of aspirin

16.) A nurse assessing a client with SIADH would expect to find laboratory values of:

1. Serum Na= 150 mEq/L and low urine osmolality
2. Serum K= 5 mEq/L and low serum osmolality
3. Serum Na=120 mEq/L and low serum osmolality
4. Serum K= 3 mEq/L and high serum osmolality

17.) A priority nursing diagnostic for a client admitted to the hospital with a diagnosis of diabetes insipidus is:

1. Sleep pattern deprivation related nocturia
2. Activity intolerance r/t muscle weakness
3. Fluid volume excess r/t intake greater that output
4. Risk for impaired skin integrity r/t generalized edema

18.) A client admitted with a pheochrocytoma returns from the operating room after adrenalectomy. The nurse should carefully assess this client for:

1. Hypokalemia
2. Hyperglycemia
3. Marked Na and water intake
4. Marked fluctuations in BP

19.) When caring for client in thyroid crisis, the nurse would question an order for:

1. IV fluid
2. Propanolol (Inderal)
3. Prophylthiouracil
4. A hyperthermia blanket

20.) A client is prescribed levothyroxine (Synthroid) daily. The most important instruction to give the client for administration of this drug is:

1. Taper dose and discontinue if mental and emotional statuses stabilize
2. Take it at bedtime to avoid the side effects of nausea and flatus
3. Call the M.D. immediately at the onset of palpitations or nervousness
4. Decrease intake of juices and fruits with high potassium and calcium contents

21.) The nurse would question which medication order for a client with acute-angled glaucoma?

1. Atropine (Atrposil) 1-2 drops in each eye now
2. Hydrochloride (Diuril) 25 mg PO daily
3. Propanolol (Inderal) 20 mg PO 2 times a day
4. Carbanyl choline (Isopto carbachol) eye drops; 1 drop 2 times a day

22.) A client tells you she has heard that glaucoma may be a hereditary problem and she is concerned about her adult children. What is the best response?

1. “There is no need for concern; glaucoma is not hereditary order.”
2. “Screening for glaucoma should be included in an annual eye exam for everyones over 50.”
3. “There may be a genetic factor with glaucoma and your children over 30 y/o should be screened yearly.”
4. “Are your grandchildren complaining of any eye problems? Glaucoma generally skips a generation.”

23.) What will be important to include in the nursing care for the client with angle-closure glaucoma?

1. Evaluation of medications to determine if any of them cause an increase in IOP is a side effect.
2. Observation for an increase in loss of vision; it can be reversed if promptly identified.
3. Control BP to decrease the client’s potential
   loss of peripheral vision.
4. Assessment for a level of discomfort; the client may experience considerable pain until the optic nerve atrophies

24.) A child is scheduled for a myringotomy. What goal of this procedure will the nurse discuss with the parents?

1. Promote drainage from the ear
2. Irrigate the Eustachian tube
3. Correct a malformation in the inner ear
4. Equalize pressure on the tympanic membrane

25.) After a client’s eye has been anesthetized, what instructions will be important for the nurse to give the client?

1. Do not watch TV for at least one day
2. Do not rub the eye for 15-20 minutes
3. Irrigate the eye every hour to prevent dryness
4. Wear sunglasses when in direct sunlight for the next 6 hours

26.) A child diagnosed with conjunctivitis. Which statement reflects that the child understood the nurse’s teaching?

1. “It’s okay for me to let my friends use my sunglasses while we are playing together.”
2. “It’s okay for me to softly rub my eye, as long as I use the back of my hand.”
3. “I can pick the crustly stuff out of my eyelashes with my fingers when I wake up in the morning.”
4. “I will use my own washrag and towel while my eyes are sick.”

27.) What medication would the nurse anticipate giving a client with Meniere’s dse?

1. Nifedipine
2. Amoxicillin
3. Propanolol
4. Hydrochloride (Hydro DIURIL)

28.) When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid?

1. Provides mechanical transmission for damaged part of the ear
2. Stimulates the neural network of the inner ear to amplify sound
3. Amplifies sound but does not improve the ability to hear
4. Tunes out extraneous noise in the lower-frequency sound spectrum

29.) What statement by the client recovering from cataract surgery would indicate to the nurse need for additional teaching?

1. “I’ll call if I have a significant amount of pain.”
2. “I’ll continue to take my Metamucil for another week.”
3. “I’ll just do some laundry this afternoon instead of going to work.”
4. “I’ll take my acetazolamide (Diamox) drops with my other morning medications

30.) A client is walking down the hall and begins to experience vertigo. What is the most important nursing action when this occurs?

1. Have the client sit in a chair and lower his head
2. Administer meclizine (Antivert) PO
3. Assist the client to sit or lie down
4. Assess if the occurrence is vertigo or dizziness

31.) Which client is at highest risk for retinal detachment?

1. 4-year old with amblyopia
2. 17 y/o who plays physical contact
3. 33 y/o with severe ptosis and diplopia
4. 72 y/o with nystagmus and Bell’s palsy

32.) To promote and maintain safety for a client after a stapedectomy. What would be included in the nursing care plan?

1. Implement fall precautions
2. Prevent aspirations
3. Begin oxygen 2-4L/min via nasal cannula
4. Change inner ear dressing when saturated

33.) The nurse would question the administration of which eye drop in a patient with increased ICP?

1. Artificial tears
2. Betaxolol (Betoptic)
3. Acetazolamide (Diamox)
4. Epinephrine HCL (Epirate)

34.) A client is being admitted for problems with Meniere’s disease. What is most important to the nurse to assess?

1. Diet history
2. Screening hearing test
3. Effect on client’s activities of daily living (ADLs)
4. Frequency and severity

35.) A client calls the nurse regarding an accident that just occurred during which an unknown chemical was splashed in his eyes. What is the most important for the nurse to tell the client to do immediately?

1. Rinse the eye with large amount of water or saline solution
2. Put a pad soaked in the sterile saline solution over the eye
3. Go to the closest emergency room
4. Have a co-worker visually checks the eye for a foreign body

36.) A 25- year old woman comes to the clinic complaining of dizziness, weakness and palpitations. What will be important for the nurse to initially evaluate when obtaining the health history?

1. Activity and exercise patterns
2. Nutritional patterns
3. Family health status
4. Coping and stress tolerance

37.) A child with leukemia is being discharged after beginning chemotherapy. What instructions will the nurse include in the teaching plan for the parents of this child?

1. Provide a diet low in protein and high in carbohydrates
2. Avoid fresh vegetables that are not cooked or peeled
3. Notify the M.D. if the child’s temperature exceeds 101F (39C)
4. Increase the use of humidifiers throughout the house

38.) Which client is most likely to have iron deficiency anemia?

1. A client with cancer receiving radiation therapy twice a week
2. A toddler whose primary nutritional intake is milk
3. A client with peptic ulcer who had surgery 6 weeks ago
4. A 15-year old client in sickle cell crisis

39.) A client has an order for one unit of whole blood. What is a correct nursing action?

1. Initiate an IV with 5% dextrose in water (D5W) to maintain a patent access site
2. Initiate the transfusion within 30 minutes of receiving the blood
3. Monitor the client’s vital signs for the first 5 minutes
4. Monitor V/S every 2 hours during the transfusion

40.) The nurse is caring for a client who is receiving a blood transfusion. The transfusion was started 30 mins ago at a rate of 100 ml/hr. The client begins to complain of low back pain and headache and is increasing restless, what is the first nursing action?

1. Slow the infusion and evaluate the V/S and client’s history of transfusion reaction
2. Stop the transfusion, disconnect the blood tubing and begin a primary infusion of normal saline solution
3. Stop the infusion of blood and begin infusion of NSS from the Y connector
4. Recheck the unit of blood for correct identification numbers and cross-match information

41.) The nurse is preparing to start an IV infusion before the administration of a unit of packed red blood cells, what fluid will the nurse select to maintain the infusion before hanging the unit of blood?

1. D5W
2. D5W/.45NaCl
3. LR solution
4. .9% Na Cl

42.) A client in sickle cell crisis is admitted to the emergency department what are the priorities of care?

1. Nutrition, hydration, electrolyte balance
2. Hydration, pain management, electrolyte balance
3. Hydration, oxygenation, apin management
4. Hydration, oxygenation, electrolyte balance

43.) A client in the ICU has been diagnosed with DIC. The nurse will anticipate administering which of the following fluids?

1. Packed RBC
2. Fresh Frozen plasma (FFP)
3. Volume expanders, such as D10W
4. Whole blood

44.) The nurse is assessing a client who has been given a diagnosis of polycythemia vera. What characteristics will the nurse anticipate finding when assessing this client?

1. Increased fatigue and bleeding tendencies
2. Hemoglobin below 13 mg/dl
3. Headaches, dyspnea, claudication
4. Back pain, ecchymosis, and joint tenderness

45.) A client has been diagnosed with pernicious anemia what will the nurse teach this client regarding medication he will need to take after he goes home?

1. Monthly Vit. B12 injections will be necessary
2. Ferrous sulfate PO daily will be prescribed
3. Coagulation studies are important to evaluate medications
4. Decrease intake of leafy green vegetables because of increased Vit. K

46.) First postop day after a right lower lobe (RLL) lobectomy, the client breathes and coughs but has difficulty raising mucus. What indicates that the client is not adequately clearing secretions?

1. Chest x-ray film shows right sided pleural fluid
2. A few scattered crackles on RLL on auscultation
3. PCO2 increases from 35-45 mm Hg
4. Decrease in forced vital capacity

47.) What nursing observations indicate that the cuff on an endotracheal tube is leaking?

1. An increase in peak pressure on the ventilator
2. Client is able to speak
3. Increased swallowing efforts by client
4. Increased crackles (rales) over left lung field

48.) The client with COPD is to be discharged home while receiving continuous oxygen at a rate of 2 L/min via cannula. What information does the nurse provide to the client and his wife regarding the use of oxygen at home?

1. Because of his need for oxygen, the client will have to limit activity at home
2. The use of oxygen will eliminate the client’s shortness of breath
3. Precautions are necessary because oxygen can spontaneously ignite and explode
4. Use oxygen during activity to relieve the strain on the client’s heart

49.) The wife of a client with COPD is worried about caring for her husband at home. Which statement by the nurse provides the most valid information?

1. “You should avoid emotional situations that increase his shortness of breathe.”
2. “Help your husband arrange activities so that he does as little walking as possible.”
3. “Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening.”
4. “Your husband will be no more short of breath when he walks but that will not hurt him.”

50.) Which statement correctly describes suctioning through an endotracheal tube

1. The catheter is inserted into the endotracheal tube; intermittent suction is applied until no further secretions are retrieved; the catheter is then withdrawn.
2. The catheter is inserted through the nose, and the upper airway is suctioned; the catheter is then removed from the upper airway and inserted into the endotracheal tube to suction the lower airway
3. With suction applied, the catheter is inserted into the endotracheal tube; when resistance is met, the catheter is slowly withdrawn
4. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

Answers and Rationales

1. A. Feel the client and bed for dampness
2. C. Check the dressing all the back of the neck for bleeding
3. A. Steatorrhea, abd. Pain, fever
4. B. Administer 50% glucose IV
5. A. Calcium chloride
6. A. Enhances the transport of glucose across cell walls
7. A. During exercise the body will use carbohydrates for energy production, which in turn will decrease the need for insulin
8. A. Fluid edema in the retro-orbital tissues which force the eyes to protrude
9. A. Diaphoresis
10. D. Come to the clinic at the earliest convenience to have blood drawn
11. A. Urine specific gravity
12. A. Increased blood glucose level
13. D. Central obesity
14. B. 1100 and 1700 hours
15. C. Should be taken with meals
16. C. Serum Na=120 mEq/L and low serum osmolality
17. B. Activity intolerance r/t muscle weakness
18. D. Marked fluctuations in BP
19. D. A hyperthermia blanket
20. C. Call the M.D. immediately at the onset of palpitations or nervousness
21. A. Atropine (Atrposil) 1-2 drops in each eye now
22. C. “There may be a genetic factor with glaucoma and your children over 30 y/o should be screened yearly.”
23. A. Evaluation of medications to determine if any of them cause an increase in IOP is a side effect.
24. A. Promote drainage from the ear
25. B. Do not rub the eye for 15-20 minutes
26. D. “I will use my own washrag and towel while my eyes are sick.”
27. D. Hydrochloride (Hydro DIURIL)
28. C. Amplifies sound but does not improve the ability to hear
29. C. “I’ll just do some laundry this afternoon instead of going to work.”
30. C. Assist the client to sit or lie down
31. B. 17 y/o who plays physical contact
32. A. Implement fall precautions
33. D. Epinephrine HCL (Epirate)
34. D. Frequency and severity
35. A. Rinse the eye with large amount of water or saline solution
36. B. Nutritional patterns
37. B. Avoid fresh vegetables that are not cooked or peeled
38. B. A toddler whose primary nutritional intake is milk
39. B. Initiate the transfusion within 30 minutes of receiving the blood
40. B. Stop the transfusion, disconnect the blood tubing and begin a primary infusion of normal saline solution
41. D. .9% Na Cl
42. C. Hydration, oxygenation, apin management
43. B. Fresh Frozen plasma (FFP)
44. C. Headaches, dyspnea, claudication
45. A. Monthly Vit. B12 injections will be necessary
46. C. PCO2 increases from 35-45 mm Hg
47. B. Client is able to speak
48. A. Because of his need for oxygen, the client will have to limit activity at home
49. C. “Arrange a schedule so your husband does all necessary activities before noon; then he can rest during the afternoon and evening.”
50. D. The catheter is inserted into the endotracheal tube to a point of resistance, and intermittent suction is applied during withdrawal.

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