Extract:

Question 1 of 5

A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse should assess the client for which of the following fears common in this age group?

Correct Answer: C

Rationale: School-age children (7 years) commonly fear injury and pain, especially in medical settings, due to their growing awareness of bodily harm.

Question 2 of 5

A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?

A. 164/90 mm Hg B. 156/89 mm Hg C. 140/94 mm Hg D. 128/84 mm Hg

Correct Answer: D

Rationale: Normal blood pressure readings are less than 120/80 mm Hg. A blood pressure reading between 120/80 mm Hg and 139/89 mm Hg is considered to be a prehypertensive state. From the readings provided in the options, the correct option identifies the most successful outcome, although the reading indicates a prehypertensive state.

Question 3 of 5

A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?

A. Instill the eyedrops whenever the eyes feel irritated B. The medication may cause some transient eye discomfort C. Keep the medication refrigerated between doses D. The need to use the eyedrops will be reevaluated after 1 month

Correct Answer: B

Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.

Question 4 of 5

Select the basic sterile asepsis procedures that are accurate. Select all that apply:

A. Sterile items ONLY are placed on the sterile field. B. The nurse must keep the sterile field below waist level. C. Coughing or sneezing over the sterile field contaminates the sterile field. D. The nurse must maintain a 1/2 inch border around the sterile field that is not sterile. E. Moisture and wetness contaminate the sterile field. F. Sterile masks are used by staff and the client when a sterile field is being set up and/or maintained

Correct Answer: A,C,E

Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).

Question 5 of 5

An adult client has been admitted to the hospital with a 3-day history of uncontrolled vomiting and diarrhea. Which should the nurse assess for in this client? Select all that apply.

A. Excitability B. Bradycardia C. Hypertension D. Poor skin turgor E. Flat peripheral veins

Correct Answer: D,E

Rationale: The client described in the question will most likely be dehydrated because of uncontrolled vomiting and diarrhea. The nurse assesses this client for weight loss, lethargy, or headache; sunken eyes; poor skin turgor (such as tenting); flat neck and peripheral veins; tachycardia; and low blood pressure.