A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nystagmus

Astigmatism

Client reports sharp pain

Loss of central vision

Answer and Explanation

The Correct Answer is D

Age-related macular degeneration is a progressive retinal disorder affecting the macula, the portion of the retina responsible for central detailed vision. Degeneration of macular photoreceptor cells leads to impaired visual acuity, difficulty reading, and reduced ability to recognize faces or perform fine visual tasks. Peripheral vision is typically preserved, but central vision progressively deteriorates. Nurses caring for clients with this condition should recognize characteristic visual changes associated with retinal damage.

Rationale:
A. Nystagmus is an involuntary rhythmic eye movement commonly associated with neurologic disorders, vestibular dysfunction, or congenital visual impairment. It is not a characteristic finding of macular degeneration because the disorder primarily affects retinal central vision rather than ocular motor control. Therefore, this finding would not be expected.

B. Astigmatism is a refractive error caused by irregular curvature of the cornea or lens, leading to blurred vision at multiple distances. It is unrelated to retinal degeneration and does not result from macular damage. Macular degeneration affects the retina itself rather than the refractive structures of the eye.

C. Sharp eye pain is not typically associated with macular degeneration. The condition is generally painless because retinal degeneration does not stimulate pain receptors. Sudden or severe ocular pain would suggest another disorder such as glaucoma, corneal injury, or acute inflammation rather than Macular degeneration.

D. Loss of central vision is the hallmark finding of macular degeneration due to progressive deterioration of the macula. Clients commonly report blurred or distorted central vision, difficulty reading, or dark spots in the center of their visual field. Peripheral vision is often maintained despite significant central visual impairment.

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Correct Answer is B

Explanation

A 12-lead electrocardiogram (Electrocardiogram (ECG)) is used to evaluate cardiac rhythm, identify dysrhythmias, and detect myocardial ischemia or other conduction abnormalities. Accurate ECG recording depends on proper electrode placement and minimizing artifacts that can distort the tracing. Patient cooperation is essential during the procedure to ensure clear interpretation of cardiac electrical activity. Nursing actions focus on preparation, positioning, and maintaining a stable recording environment.

Rationale:
A. Attaching a blood pressure cuff is not required for obtaining a 12-lead ECG. While vital signs may be monitored as part of overall cardiac assessment, the blood pressure cuff is not part of the ECG setup and does not influence the quality of the tracing. It is not a priority action during ECG acquisition.

B. Instructing the client to remain still is essential because movement can cause electrical artifacts that interfere with accurate interpretation of the cardiac rhythm. Muscle activity, talking, or shifting positions can distort waveforms and lead to misinterpretation of dysrhythmias. Ensuring the client remains still helps produce a clear and reliable ECG tracing.

C. The orthopneic position is used to facilitate breathing in clients with respiratory distress, not for ECG acquisition. The preferred position for a 12-lead ECG is supine to allow proper electrode placement and minimize movement. Orthopneic positioning may interfere with electrode contact and lead to inaccurate results.

D. A 12-lead ECG is a painless, noninvasive procedure that does not involve electrical stimulation or injections. Clients may feel slight coolness from electrode gel but no stinging sensation. Therefore, instructing the client to expect a stinging sensation is incorrect and may cause unnecessary anxiety.

A. Position the client supine for 1 hr following the feeding. B. Withhold the feeding if 50 mL of residual is present. C. Elevate the head of the bed 20 degrees. D. Administer 30 mL of water prior to the feeding.

Correct Answer is D

Explanation

Intermittent enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube is used to provide nutrition directly into the stomach for clients who cannot meet nutritional needs orally. Safe administration requires preventing tube occlusion, reducing aspiration risk, and ensuring proper placement and patency of the feeding tube. Nursing care includes appropriate positioning, flushing protocols, and monitoring for gastric residuals. Proper technique supports tolerance of feeding and reduces complications such as aspiration pneumonia and tube blockage.

Rationale:
A. Positioning the client supine for 1 hour following feeding is incorrect because lying flat increases the risk of aspiration. Gastric contents may reflux into the esophagus and airways, especially in clients receiving enteral nutrition. The head of the bed should be elevated during and after feeding to promote gastric emptying and reduce aspiration risk.

B. Withholding feeding if 50 mL of residual is present is not a universal guideline because acceptable residual volumes vary by facility policy. In many cases, 50 mL is considered within acceptable limits and does not require holding the feeding unless accompanied by other signs of intolerance. Clinical judgment and institutional protocols should guide management.

C. Elevating the head of the bed 20 degrees is insufficient to prevent aspiration. The recommended position for enteral feeding is typically 30–45 degrees elevation to reduce the risk of reflux and aspiration. Lower elevations do not provide adequate protection during feeding.

D. Administering 30 mL of water prior to the feeding is correct because flushing the PEG tube ensures patency and helps prevent clogging. It also verifies that the tube is clear before delivering nutrition. In care of clients with devices such as Percutaneous endoscopic gastrostomy (PEG) tube, routine water flushes before and after feedings are essential for maintaining tube function and safe nutrition delivery.

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A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is planning to administer an intermittent enteral feeding through a client's percutaneous endoscopic gastrostomy (PEG) tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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