A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Initiate a referral for ophthalmic evaluation as soon as possible.

Advise the client to maintain normal activities, but avoid contact sports until the spots resolve

Instruct the client to rest, and report to the emergency department if eye pain develops.

Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Answer and Explanation

The Correct Answer is A

A.   The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B.   This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C.   While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D.   Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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Correct Answer is B

Explanation

A. While hypercalcemia associated with hyperparathyroidism can lead to neurological symptoms, seizures are not a typical presentation of kidney stones.
B. Sudden onset of severe flank pain in a client with hyperparathyroidism is highly suggestive of a kidney stone. Straining the urine to check for stones is a crucial nursing action.
C. Laxatives are not indicated for the management of kidney stones.
D. While hypercalcemia can lead to cardiac arrhythmias, this is not the immediate priority when the client is experiencing severe flank pain suggestive of kidney stones.

A. Client's breath sounds are clear to auscultation bilaterally. B. Client exhibits a frequent productive cough. C. Client demonstrates proper use of an incentive spirometer. D. Client reports using the incentive spirometer every hour while awake.

Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

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A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?