The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

Recent change in the ability to read and drive after dark.

Gradual onset of continuous eye pain and blurred vision.

Cloudy opacity of the crystalline lens.

Gray-white circle around the iris of both eyes.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Recent change in the ability to read and drive after dark: This may indicate the onset of cataracts or age-related night vision decline, which is common in older adults. While it should be documented and followed up, it is not considered an urgent or emergent finding.

B. Gradual onset of continuous eye pain and blurred vision: This may suggest the development of angle-closure glaucoma or another serious ocular pathology, where increasing intraocular pressure could lead to permanent vision loss if not treated promptly.

C. Cloudy opacity of the crystalline lens: A cloudy lens is characteristic of cataracts, a common, non-urgent age-related change in older adults. Although it affects vision over time, it progresses slowly and can be addressed during routine follow-up care or elective surgery.

D. Gray-white circle around the iris of both eyes: This describes arcus senilis, a benign finding caused by lipid deposits in the corneal margin. It is common with aging and usually has no impact on vision or underlying pathology requiring urgent referral unless seen in younger adults.

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Correct Answer is B

Explanation

Rationale:

A. Before changing assignments, determine which staff members have fitted particulate filter masks: This option suggests rearranging assignments based on respirator fit, but a particulate filter mask (like an N95) is not required for droplet precautions. The focus should be on educating the UAP rather than altering assignments unnecessarily.

B. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client: Droplet precautions require a standard surgical mask, not a particulate filter mask. The nurse should clarify this with the UAP to ensure proper precautions are followed without unnecessary changes or delays in care.

C. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care: This adds unnecessary steps. For droplet precautions, a surgical mask is sufficient for all aspects of client care. There's no need to delay care or obtain a filter mask fitting.

D. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client: This is not necessary for droplet precautions, as it reflects confusion with airborne precautions (e.g., for tuberculosis). The nurse should correct the misunderstanding rather than escalate it.

A. A B. B C. C D. D

Correct Answer is B

Explanation

Rationale:

A: This shows the IV insertion site on the hand. While important for checking infiltration or phlebitis, it does not affect flow rate or volume delivered, so it's not the priority in fluid overload.

B: This shows the IV drip chamber. This is the first place to assess because it allows the nurse to determine how fast the IV fluid is infusing. It provides a quick visual cue of the actual flow rate, which is essential in evaluating whether the infusion is too fast, the likely cause of the overload.

C: This is the IV tubing near the insertion site. Kinks or dislodgement can affect flow, but it’s not the most immediate concern when fluid overload is suspected.

D: Shows the roller clamp, this directly controls the flow rate in a gravity system, so it is the place to intervene when fluid overload is suspected. After assessing the flow rate in the drip chamber and confirming fast infusion, the nurse should adjust the flow rate at this part.

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The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assigns an unlicensed assistive personnel (UAP) to a client who has been placed on droplet precautions for a respiratory infection. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is B

Explanation

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

Correct Answer is B

Explanation

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