The client has cancer. He asks the nurse where cancer comes from. What is the best
explanation by the nurse?
1. "Cigarette smoking and second-hand smoke are the primary causes of cancer."
2. "Cancer is genetic; you inherited the predisposition for your ca
Answer: 4
Rationale: Cancer is thought to result from damage to the genes controlling cell growth.
Cigarette smoking and second-hand smoke are carcinogens that can lead to the
development of cancer, but this is not the best answer. Some cancer is genetic,
The nurse teaches a support group about the causes of cancer for families of
individuals with cancer. The nurse evaluates learning has occurred when the clients
make which statement(s)? Select all that apply.
1. "Some cancers have a strong genetic compone
Answer: 1 2, 4
Rationale: Some cancers have a strong genetic component. Cancers have a very strong environmental component. Cancer can result from damaged, tumor-suppressor
genes. There is no evidence to support that suppressed anger and rage will result
The client has recently been diagnosed with cancer. The nurse develops a plan to teach the client about the most effective treatment(s) for cancer. What will the best plan(s) of the nurse include? Select all that apply.
1. Alternative medicine
2. Surgery
Answer: 2 3, 4
Rationale: The three treatments for cancer are surgery, radiation therapy, and chemotherapy. Alternative medicine is not considered a very effective treatment for cancer at this point. Photodynamic therapy is used for some type of cancers,
The nursing instructor teaches student nurses about chemotherapy for cancer. Which
statement best explains why lung cancers are less sensitive to antineoplastic agents than
other types of cancers?
1. "Lung cancer cells have a low-growth fraction, which me
Answer: 1
Rationale: Growth fraction is a ratio of the number of replicating cells to the number of resting cells. Antineoplastic drugs are much more toxic to tissues and tumors with high growth fractions. Breast and lung cancers have low-growth fractions
The client receives tamoxifen (Nolvadex) for treatment of breast cancer. She asks the nurse why the medicine works. What is the best response by the nurse?
1. "Tamoxifen (Nolvadex) works by inhibiting the metabolism of breast cancer cells."
2. "Tamoxifen
Answer: 2
Rationale: Breast cancer is dependent on estrogen for growth. Tamoxifen (Nolvadex) acts by blocking estrogen receptors; the tumor is deprived of estrogen.Tamoxifen (Nolvadex) does not inhibit the metabolism of breast cancer cells.Tamoxifen
(Nolv
The nurse assesses several clients for their potential risk for developing cancer.
Which client does the nurse assess to be at highest risk for developing cancer?
1. The client who usually applies sunscreen when arriving at the beach
2. The client who is
Answer: 2
Rationale: Alcoholism and consuming large amounts of red meat are lifestyle factors that put this client at risk for developing cancer. Application of sunscreen at the beach
will help prevent skin cancer. Being 10 pounds overweight is probably n
The client receives cyclophosphamide (Cytoxan) as treatment for cancer, and is experiencing oral irritation as an adverse effect. What does the best plan of the nurse include as it relates to providing oral comfort?
Teach the client to avoid extreme temperatures of food selections.
The nursing instructor teaches the student nurses about intrinsic factor. The
instructor evaluates learning has occurred when the students make which response?
I. "Intrinsic factor is necessary for absorption of vitamin B 12."
2. "Intrinsic factor is secr
Answer: I
Rationale:U Parietal cells secrete intrinsic factor, which is essential for the absorption of vitamin B12. Chief cells secrete pepsinogen and rennin, not intrinsic factor. Intrinsic factor is necessary for the absorption of vitamin B12, not B6.
The physician has ordered bismuth (Pepto-Bismol) for the client with a peptic ulcer
who is colonized with H Pylori.U The chent asks the nurse why he is receiving this drug.
What is the best response by the nurse? Select all that apply.
I. "Bismuth (Pepto-
Answer: 2 4
Rationale: Bismuth compounds (Pepto-Bismol) are added to the antibiotic regimen to inhibit bacterial growth. Bismuth compounds (Pepto-Bismol) prevent H Pylori from adhering to the ~astric mucosa. Bismuth (Pepto-Bismol) does not prevent the sid
The physician orders misoprostol (Cytotec) for the female client with peptic ulcer disease (PUD). What is a priority question for the nurse to ask the client prior to administration of this medication?
I. "Are your menstrual cycles irregular?"
2. "Are you
Answer: 2
Rationale: Misoprostol (Cytotec) is contraindicated during pregnancy; it is sometimes used to terminate pregnancies.U There is no contraindication for misoprostol (Cytotec) in
a client with irregular menstrual cycles. Misoprostol (Cytotec) is sa
The client receives esomeprazole (Nexium). He asks the nurse why that little purple
pill is better than his cimetidine (Tagamet). What is the best response by the nurse? 1. "It is not as effective as cimetidine (Tagamet), but kills bacteria better."
2. "I
Answer: 4
Rationale:U Proton-pump inhibitors reduce acid secretion to a greater extent than H2-receptor antagonists, and have a longer duration of action. Esomeprazole (Nexium) is more effective than cimetidine (Tagamet), but will not kill bactena. Esomep
The client is admitted for treatment of a duodenal ulcer. During the client's
admission, what will the best assessment of the nurse reveal?
1. Low back pain radiating down the left leg.
2. Anorexia and weight loss.
3. Burning pain several hours after eati
Answer 3
Duodenal ulcers are associated with burning upper abdominal pain after a meal. Duodenal ulcers do not cause low back pain radiating down the left leg. Anorexia and weight loss are more common with gastric, not duodenal, ulcers. Nausea and lower
r
The nurse has completed education about peptic ulcer disease (PUD) with the
client.U The nurse evaluates learning has occurred when the client makes which
statement?
1. "I will join a gym and increase my exercise."
2. "I will drink more milk and limit spi
Answer: 4
Rationale: Caffeine is a risk factor for peptic ulcer disease (PUD), so limiting caffeine will be beneficial in the treatment of peptic ulcer disease (PUD). There is no correlation between exercise and the management of peptic ulcer disease (PUD
An elderly client comes to the emergency department with his wife. He has a history
of peptic ulcer disease (PUD), and is currently experiencing confusion and severe
headaches. What does the best plan of the nurse include?
I. Obtain a magnetic resonance i
Answer: 3
Rationale: There is a known correlation between H2-receptor antagonists and confusion and headaches in the elderly population, the nurse should ascertain what medications the
client is taking. It is premature to obtain a magnetic resonance imagi
The client has gastroesophageal reflux disease (GERD) and has been receiving
medication treatment for many years. What priority assessment findings associated with
the medication must the nurse report to the physician?
1. Hypotension and tachycardia
2. An
Answer: 2
Rationale: Anemia, fatigue, and weakness are common signs of pernicious anemia or vitamin B12 deficiency. With chronic suppression of stomach acid by medications used
for gastroesophageal reflux disease (GERD), the stomach may not be able to abs
The physician has ordered combination therapy for the client with peptic ulcer
disease (PUD).U The nurse plans to do medication education. What will the best plan of
the nurse include?
1. Combination therapy has the best outcomes when antibiotics are used
Answer; 2
Rationale: Combination therapy has the best outcomes when antibiotics are used with proton-pump inhibitors. Combmation therapy has the best outcomes when antibiotics are used With proton-pump inhibitors, not with antacids. Combination therapy ha
The nursing instructor is teaching student nurses about lower gastrointestinal (GI)
functioning and the large intestine. The nursing instructor evaluates learning has
occurred when the students make which statement?
1. "The large intestine absorbs water a
Answer: 1
Rationale: Major functions of the large intestine include absorption of water and elimination of stool. The small intestine, not the large intestine, absorbs most of the
nutrients from food. The large intestine contains host flora that manufactu
The elderly client has constipation. He asks the nurse the reason for this. What is the best response by the nurse?
1. "Your large intestine is old and does not work as well as it used to."
2. "You don teat enough fiber, so the stool stays in your intesti
Answer: 2
Rationale: Water is reabsorbed in the large intestine. If the waste material remains in the intestine too long due to lack of fiber, too much water is reabsorbed leading to small, hard
stools. Telling an elderly client that his intestine is old
The nurse designs a teaching plan for the client with chronic pancreatitis who receives pancrelipase (Pancrease). What will the best plan of the nurse include as it relates to the rationale for the client to receive this drug?
1. "These enzymes promote di
Answer: 4
Rationale: Chronic pancreatitis eventually leads to pancreatic insufficiency that may necessitate replacement of pancreatic enzymes. Pancreatic enzymes promote digestion of
starches, fats, and proteins. Pancreatitis enzymes do not help heal the
The client receives sibutramine (Meridia). What will be a priority assessment by the nurse?
1. Urinary output
2. Blood pressure
3. Daily weight
4. Peripheral edema
Answer: 2
Rationale: The nurse must assess the client's blood pressure, as hypertension is a side effect of sibutramine (Meridia).O There is no need to assess the client's urinary output.O The client's weight must be monitored, but not on a daily basis. P
The nurse is planning care for the client who experiences frequent constipation. What will the best plan of the nurse include? Select all that apply.
1. Drink a glass of water every hour
2. Increase dairy products in the diet
3. Increase dietary fiber in
Answer 3, 4
Rationale: Increasing fiber in the diet will help prevent constipation. Increasing exercise
will help prevent constipation. Drinking a glass of water every hour is too much fluid and
can result in hyponatremia. Dairy products in the diet will
The client is scheduled for bowel surgery. What medications are appropriate for the "bowel prep"? Select all that apply
1. Docusate sodium (Colace)
2. Bisacodyl (Ducolax)
3. Sodium phosphate (Fleet Phospho-Soda)
4. Tap-water enema
5. Glycerin suppository
Answer: 2 3, 4
Rationale: Bisacodyl (Ducolax) is a stimulant laxative and appropriate for a "bowel
prep." Sodium phosphate (Fleet Phospho-Soda) is an osmotic saline laxative and
appropriate for a "bowel prep." A tap-water enema is appropriate for a "bowel
The client is scheduled for a "bowel prep" prior to surgery. What is a critical
assessment of the nurse prior to administering the "bowel prep"?
1. The client's blood pressure
2. The client's weight
3. The client's creatinine level
4. The client's hemoglo
Answer: 3
Rationale: Assessing kidney function, creatinine level, is critical because the client must
be able to excrete a large volume of fluid with a "bowel prep." Blood pressure is always
important, but not the priority for a "bowel prep." Assessing th
The physician has prescribed orlistat (Xenical) for the obese client. The nurse knows the client has been eating too much fatty food in her diet when she reports which adverse effect?
1. Constipation
2. White stools
3. Foul-smelling stools
4. Oily stools
Answer: 4
Rationale: Clients who ingest increased fat in their diet while receiving orlistat (Xenical) will experience urgent, oilY. stools. Constipation does not occur when the client ingests increased fat in their diet while receiving orhstat (Xenical).
The client has been vomiting for several days. What will the best assessment of the
nurse include?
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic alkalosis
4. Metabolic acidosis
Answer: 3
Rationale: Metabolic alkalosis will result from excessive loss of hydrochloric acid from the stomach brought on by prolonged vomiting. Respiratory acidosis will not occur as a
result of vomiting. Respiratory alkalosis will not occur as a result
The client takes a stool softener on a regular basis and now reports a change in
bowel patterns. Which assessment data would the nurse report to the physician?
1. An increase in bowel frequency
2. A decrease in bowel frequency
3. Cramping with each stool
Answer: 3
Rationale: Cramping could indicate a serious condition that should be reported to the physician. An increase in bowel frequency does not need to be reported at this time. A
decrease in bowel frequency does not need to be reported at this time. S
The client asks the nurse about the advantages of mast cell stabilizers over
antihistamines in the treatment of allergies. What is the best response by the nurse?
1. "They relieve the clinical symptoms more effectively."
2. "They act on a cellular level t
Answer: 3
Rationale: The greatest impact of the mast cell stabilizers is that they can be used as prevention of the allergic, or clinical, response. Mast cell stabilizers do not treat symptoms more effectively; they are best for prevention of the allergic
The client tells the nurse that her symptoms have become worse since she has been
using oxymetazoline (Afrin) for nasal congestion. What is the best assessment question
for the nurse to ask?
1. "Can you describe how your symptoms have gotten worse?"
2. "H
Answer: 2
Rationale: Oxymetazoline (Afrin) can cause rebound congestion if used for too long, so length oftreatment is the best assessment question.\! The problem is rebound congestion, asking the client to describe her symptoms is unnecessary. The proble
3 Which assessment finding. by the nurse, is a priority concern when a client receives
pseudoephedrine (Sudafed) 60 mg PO every 4 hours?
1. Blood pressure of 150/60 mmHg
2. Temperature of 100� F
3. Complaints of a dry mouth
4. Respiratory rate of 22
Answer: 1
Rationale: Psuedoephedrine (Sudafed) is a vasoconstrictor and can increase blood pressure.P A temperature is possible with pseudoephedrine (Sudafed), but is not the primary concemJ,} A dry mouth is possible with pseudoephedrine (Sudafed), but is
The elderly client receives diphenhydramine (Benadryl) for allergies.U The nurse
completes medication education and evaluates learning has occurred when the client
makes which statement?
1. "If my nose begins to run, I can use a nasal spray."
2. "Constipa
Answer: 2
Rationale: Constipation is a common side effect of antihistamines.U Antihistamines dry, not increase, secretions. Sodium intake is not related to antihistamines. Pseudoephedrine (Sudafed) is commonly used with antihistamines.
5 The nurse completes medication education for the client receiving
antihistamines.U The nurse evaluates learning has occurred when the client makes which
statement?
1. "I can still have my after-dinner-drink."
2. "I need to increase fluids while taking t
Answer: 3
Rationale: Sedation is a common side effect of antihistamines. Alcohol will increase the sedative effects of antihistamines, so the client should not drink while taking antihistamines. There is no need to increase fluids when taking antihistamin
6 The nursing instructor teaches the nursing students about the major functions of the
upper respiratory tract. What will the best plan of the nursing instructor include? Select
all that apply.
1. The nasal mucosa is the first line of immunological defens
Answer: 1, 2, 3
Rationale: The nasal mucosa is the first line of immunological defense. The nose warms the air before it reaches the lungs. Activation of the sympathetic nervous system constricts arterioles in the nose. Activation of the sympathetic nervo
The client has allergic rhinitis and asks the nurse what causes this. What is the best
response by the nurse? Select all that apply.
1. "It is caused by weeds and grasses."
2. "It is caused by tobacco smoke."
3. "You inherited the predisposition for this.
Answer: 1 ,2, 3, 4
Rationale:M Allergic rhinitis is caused by weeds and grasses. Allergic rhinitis is caused by tobacco smoke.~ Allergic rhinitis is caused by animals. There is a strong genetic predisposition for allergic rhinitis.Although associated with
The nursing instructor teaches the student nurses about histamine receptors and
evaluates that further instruction is needed when the students make which statement?
1. "H1-receptors are responsible for allergic symptoms."
2. "H1-receptors are responsible
Answer: 2
Rationale: H2-receptors, not H1-receptors, are responsible for peptic ulcers. H1-receptors are responsible for allergic symptoms. H2-receptors are responsible for peptic ulcers. H2-receptors increase mucus secretion in the stomach.
The client receives diphenhydramine (Benadryl) to control allergic symptoms.
Which common symptom does the nurse teach the cfient to report to the physician?
1. Sedation
2. Urinary hesitancy
3. Diarrhea
4. Projectile vomiting
Answer: 2
Rationale: Urinary hesitancy is an anticholinergic effect of diphenhydramine (Benadryl) and should be reported to the physician. Sedation is a common side effect, but does not
need to be reported. Diarrhea is not a common side effect. Projectile
The client receives beclomethasone (Beconase) intranasally as treatment for
allergic rhinitis. He asks the nurse if this drug is safe because it is a glucocorticoid. What
is the best response by the nurse?
1. "Intranasal glucocorticoids produce almost no
Answer: 1
Rationale:~ Intranasal glucocorticoids produce almost no serious adverse effects. There is no time frame for the use of intranasal glucocorticoids, they produce almost no serious
adverse effects. There is no problem with swallowing intranasal gl
The client receives albuterol (Proventil) via inhaler. He asks the nurse why he can't
just take a pill. What is the best response by the nurse?
1. "Because this medication cannot be absorbed from your GI tract; the acid in your
stomach would destroy it.
Answer: 3
Rationale: The respiratory system offers a rapid and efficient mechanism for delivering drugs.l) The enormous surface area of the bronchioles and alveoli, and the rich blood supply to these areas, results in an almost instantaneous onset of acti
The nurse teaches a medication class on bronchodilators for clients with
asthma.l) The nurse evaluates that learning has occurred when the clients make which
statement?
1. "The medication widens our airways because it stimulates the fight-or-flight respon
Answer: 1
Rationale: During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs. Bronchodilators act on the sympathetic nervous system
The client asks the nurse why she must continue taking her asthma medication even
though she has not had an asthma attack in several months. What is the best response by
the nurse?
1. "The medication needs to be taken for at least a year; then, if you hav
Answer: 4
Rationale:P Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs. Long term treatment of asthma continues indefinitely, not for just one ye
The nurse plans to teach an adolescent about inhalation therapy as part of the
treatment plan for the client's asthma. What does the best plan of the nurse include?
1. Inhalation therapy is effective because it provides around-the-clock therapy, as
oppose
Answer: 2
Rationale:P The major advantage of aerosol therapy is that it delivers the drugs to their direct site of action. Inhalation therapy does not provide around-the-clock therapy. Inhalation therapy does not provide systemic relief of symptoms. Inhal
A client receives theophylline (Theo-Dur) and calls the clinic to say he has had
nausea and vomiting for two days. What is the best action by the nurse?
1. Recommend that the client begin a dear liquid diet.
2. Ask the client if he has been exposed to any
Answer: 3
Rationale:P Nausea and vomiting are symptoms of theophylline toxicity; the client needs
to come to the clinic for an assessment.P A clear-liquid diet might help, but the client needs to be assessed for theophylline toxicity. Flu could be the cau
The nurse teaches the client about the use of a metered-dose inhaler (MDI).P The
nurse evaluates that additional teaching is required when the client makes which
statement?
1. "I should hear a whistling sound each time I use the metered-dose inhaler (MDI)
Answer: 1
Rationale: A whistling sound indicates that the metered-dose inhaler (MDI) is not being used effectively and the client is not receiving the medication. Rinsing the mouth after using the metered-dose inhaler (MDI) is correct; it will help reduce
The client receives beclomethasone (Beconase). What will the best assessment of
the nurse include? Select all that apply.
1. Assess if the client alternates nares with administration of nasal spray.
2. Assess the client's blood glucose prior to administra
Answer: 1, 3, 4, 5
Rationale: Nares should be alternated with nasal spray. Clients may develop candidiasis so the mouth should be assessed. Clients may experience a change in voice as a local effect. The client should gently blow the nose prior to use to
The client receives ipratropium (Atrovent) via inhalation for the treatment of chronic
asthma.P The nurse plans to do medication education with the client. What will the best
plan of the nurse include? Select all that apply.
1. The medication may also be
Answer: 2, 4, 5
Rationale: Anticholinergic drugs can result in urinary retention, and the client should report any changes in urinary patterns.P A side effect of anticholinergics is sinusitis and upper respiratory tract infection, so the client should rep
The client receives isoproterenol (lsuprel) via inhalation.P The nurse determines that
the client is experiencing a side effect of this medication when reviewing which
laboratory test?
1. Creatinine of 1.0 mg/dl
2. Sodium of 160
3. AST of20 units/L 4. Glu
Answer: 4
Rationale: A side effect of isoproterenol (Isuprel) is hyperglycemia. A creatinine of 1.0 mg/dl is a normal creatinine level, and isoproterenol (Isuprel) is not nephrotoxic. A
sodium of 160 is an elevated sodium level, but isoproterenol (lsuprel
The physician has ordered ipratropium (Atrovent) for the client. What is a priority
assessment question for the nurse to ask prior to administering this medication?
1. "Do you have diabetes mellitus?"
2. "Do you have glaucoma?"
3. "Do you have seizures?
Answer: 2
Rationale: Anticholinergic drugs can worsen narrow angle glaucoma. Anticholinergic drugs do not impact glucose levels, so having diabetes mellitus is not a concern. Anticholinergic drugs do not affect seizure disorders, this is not a concern. An
The client receives zafirlukast (Accolate) as treatment for asthma.l) The nurse has
completed medication education and evaluates learning has occurred when the client
makes which statement?
1. "This medication decreases the inflammation in my lungs."
2.
Answer: 1
Rationale: Zafirlukast (Accolate) prevents airway edema and inflammation by blocking leukotriene receptors in the airways. Zafirlukast (Accolate) is not a bronchodilator. Zafirlukast (Accolate) is ineffective for acute asthma attacks. Zafirlukas
The physician has prescribed cromolyn (Intal) for the client with asthma. The
nurse plans to do medication education. What will the best plan of the nurse include?
1. This medication can affect blood glucose levels.
2. This medication is indicated for acu
Answer: 3
Rationale: By reducing inflammation, cromolyn (Intal) is able to prevent asthma attacks. Cromolyn (lntal) does not affect blood glucose levels. Cromolyn (lntal) is ineffective for acute asthma attacks. Cromolyn (Intal) does not cause hypertensio
The client has been consuming very high amounts of vitamin A. He asks the nurse
why this is a problem since it is just a vitamin. What is the best response by the nurse?
1. "It really isn't a problem; your body will just get rid of the excess vitamin."
2.
Answer: 3
Rationale: Fat-soluble vitamins can be stored in large quantities in the liver and adipose tissue.P This storage may lead to dangerously high levels if taken in excessive amounts.
Vitamin A is a fat-soluble vitamin and is not readily excreted in
2 The physician orders multivitamins for the client.P The client asks the nurse why
she needs vitamins. What will the best teaching plan by the nurse include? Select all that
apply.
1. Vitamins are organic compounds.
2. Vitamins are identified as water-so
Answer: 1 2, 3
Rationale: Vitamins are organic compounds. Vitamins are identified as water-soluble or fat-soluble. Vitamins are needed for growth and maintenance of normal metabolic processes. Vitamins are not inorganic compounds. Vitamins are great nutri
The client is receiving enteral nutrition. He reads on the bag hanging at his bedside
that the liquid is a polymeric formulation. He asks the nurse what this means. What is the
best response by the nurse?
1. "It means that your formulation contains varyin
Answer: 4
Rationale: Polymeric formulations are the most common enteral preparations. These products contain various mixtures of proteins, carbohydrates. and lipios. Oligomeric formulations are agents containing varying amounts of free amino acids and pep
The nurse has completed medication education for the client receiving iron therapy
(ferrous sulfate).~ The nurse evaluates that learning has occurred when the client makes
which statement?
1. "I should take my iron with milk so it won't upset my stomach.
Answer: 4
Rationale: Darkened stools are an expected effect of iron therapy (ferrous sulfate). The calcium and phosphorus in milk can lead to decreased absorption of iron (ferrous sulfate),
so the medication should not be taken with milk. Foods high in ph
The nurse assesses which client as being at greatest risk for developing vitamin
deficiencies?
1. The young female client who uses oral contraceptives for birth control
2. The young male client who takes phenytoin (Diiantin) for new-onset epilepsy
3. The
Answer: 1
Rationale:~ The use of oral contraceptives is associated with deficiencies of B complex vitamins. Certain anticonvulsants can be associated with B complex deficiencies, but the client is just starting therapy so he is not at great risk.~ The pre
The nurse teaches new mothers about the reason their infants receive vitamin K. The nurse evaluates instruction as being effective when the mothers make which statement?
1. "Our babies will be able to get enough vitamin K through breast milk."
2. "Our bab
Answer: 2
Rationale:~ The infant's gut is sterile, so there is inadequate bacteria to synthesize
vitamin K, which is essential to promote blood clotting. Vitamin K is not present in high
enough amounts in breast milk to protect the infant from bleeding.~
The nursing instructor teaches the student nurses about the structure and function of
the skin. What will the best teaching plan of the instructor include? Select all that apply.
1. Keratin is found in those areas subject to mechanical stress i.e., the pa
Answer: 1 3, 5
Rationale: Keratin is found in those areas subject to mechanical stress i.e., the palms of
the hands. The amount of subcutaneous tissue varies, and is determined by nutritional status and heredity . The outermost layer of the epidermis is m
The client asks the nurse how skin cells are replaced. What is the best response by
the nurse?
1. "The stratum corneum supplies new cells after older cells have been damaged or lost."
2. "The epidermis supplies new cells after older cells have been damage
Answer: 2
Rationale: The deepest epidermal sublayer, the stratum basale, supplies the epidermis with new cells after older superficial cells have been damaged or lost through normal
wear. The deepest epidermal sublayer, the stratum basale, not the stratum
The client has scabies and will be using lindane (Kwell). What is the best instruction
by the nurse?
1. Apply the medication topically to the affected area.
2. Leave the medication on the body for 24 hours.
3. Leave the medication on the body for 8 to 12
Answer: 3
Rationale: Leaving the medication on the body for 8 to 12 hours is necessary for the medication to be effective. The nurse must specify how long the medication must be left
on the skin; telling the client to apply it topically is not specific en
The client asks the nurse how glaucoma develops. What is the best response by the
nurse? Select all that apply.
1. Having blue eyes are a risk factor in the development of glaucoma."
2. "When the pressure in your eye is high enough to cause optic nerve da
Answer: 2 3, 4
Rationale: Glaucoma develops when the pressure in the eye is high enough to cause
optic nerve damage. High blood pressure can lead to the development of glaucoma.
Medications like antihistamines and antidepressants can cause glaucoma. Havin
The client asks the nurse what kind of glaucoma she has. The nurse tells her she
has open-angle glaucoma. What does the client understand this to be? Select all that
apply.
1. 'My eye cannot drain the fluid that it produces."
2. "This is a gradual process
Answer; 1 3, 4
Rationale: In cases of open-angle glaucoma. the cause for the high pressure is an imbalance in the production and drainage of fluid in the eye (aqueous humor). Open angle glaucoma often takes years to develop. Open-angle glaucoma is the mos
The client is scheduled for an eye exam. Prior to the exam the physician will put a
cycloplegic drug. atropine sulfate (Isopto Atropine) eye drops in the client's eyes. What
will the nurse teach the client about these eye drops?
1. The drops will dilate t
Answer; 3
Rationale: Cycloplegic eye drops dilate the pupil and paralyze the ciliary muscle. Cycloplegic eye drops not only dilate the pupil, but also paralyze the ciliary muscle which is necessary for visualization of the retina. Cycloplegic eye drops di
The client tells the nurse that when he uses his eye drops they sting his eyes. What is
the best response by the nurse?
1. "You should wash your eyes immediately with saline."
2. "Your eye drops may have expired; check the date."
3. "This is a normal and
Answer: 3
Rationale: It is normal for eye drops to cause stinging when used. Washing the eye with saline will dilute the eye drops; this is not recommended. The drops should cause stinging, it means they have not expired.P The physician does not need to b
The client tells the nurse that he experiences frequent eye irritation even after using
over-the-counter (OTC) medications. What is the best recommendation by the nurse?
1. See your eye doctor for further evaluation.
2. Use normal saline rinses instead of
Answer; 1
Rationale The client should follow-up with his physician if over-the-counter (OTC) remedies are ineffective for eye irritation. The client should follow-up with his physician; not use normal saline rinses. The client should follow-up with his ph
The client receives two different eye drop medications. The nurse has completed
medication education and evaluates that learmng has occurred when the client makes
which statement?
1. "I will give two drops of one medication, wait five minutes, and then gi
Answer: 1
Rationale: The correct procedure is for the client to administer one medication, wait five minutes, and then administer the other medication.The correct procedure is for the client to administer one medication, wait five minutes, not one minute,
The client receives medications for glaucoma. She asks the nurse what over-the counter (OTC) medication she can take for her allergic rhinitis. What is the best response
by the nurse?
1. "You can take an antihistamine, but avoid decongestants."
2. "You ca
Answer: 3
Rationale: Antihistamines as well as decongestants can interact with glaucoma treatment, the client must avoid both.P The client must avoid antihistamines as well as decongestants. The client must avoid antihistamines as well as decongestants. N
The client has excess cerumen in his ears. What will the best plan of the nurse
include as to the safe removal of the cerumen?
1. Instill 2% acetic acid in each ear.
2. Use a sterile Q-tip to remove cerumen.
3. Use warm water and a bulb syringe.
4. Take h
Answer: 3
Rationale: Warm water and a bulb syringe is the best method for cerumen removal Acetic acid is not the best method for cerumen removal.P A Q-tip is dangerous
as it can pack the cerumen into the ear canal. Hot showers will not facilitate drainage
The nurse has taught the client about glaucoma.P The nurse evaluates learning has
occurred when the client makes which statement?
1. "I must use my eye drops as prescribed for the rest of my life."
2. "I can stop the eye drops when the glaucoma has resolv
Answer: 1
Rationale:~ Glaucoma can be controlled, but not cured; the client must use eye drops for
the rest of his life. Glaucoma can be controlled, but it will not resolve, the client cannot stop using the eye drops. Eye drops must be used continuously;
The client has glaucoma. Which assessment finding indicates to the nurse that a
client's medical regimen could have contributed to onset of glaucoma?
1. Occasional use of antihistamines for allergies
2. Regular use of an anticholinergic drug for urinary i
Answer: 2
Rationale:~ Anticholinergic drugs can contribute to glaucoma. Occasional use of antihistamines for allergies should not be a factor. Hypertension can be a factor, but betablockers may be used to treat glaucoma. Glucocorticmds can contribute to t
The client is to receive eye drops for glaucoma. What is the correct method of
administration?
1. Place the drop in the center of the eye.
2. Place the drop so it falls on the white part of the eye.
3. Turn the head to the side so that the drop flows to t
Answer: 4
Rationale: The correct method for administering eye drops is to place the drop in the conjunctival sac below the eye.U The eye drop should be placed in the conjunctival sac below the eye, not in the center of the eye.P The eye drop should be pla
The client is to receive ear drops. What is the correct method of administration that
the nurse plans to teach the client?
1. Sit up straight and turn your head to the side.
2. Lie on the unaffected side to instill .r,our drops.
3. Hold your head back whi
Answer: 2
Rationale: Lying on the unaffected side will facilitate the flow of drops into the ear. The client should lie on the unaffected side, not hold the head back. The client should lie on the unaffected side, not prop the head on a pillow after admin