The nurse is working in an urgent care clinic that has standardized treatment protocols for implementation by nursing staff. After reviewing the history. physical assessment, and vital signs for a 60-yr-old patient as shown in the accompanying figure, which action should the nurse take first?
Report a vision change to the health care provider.
Check the patient's blood glucose level.
Use an irrigating syringe to clean the ear canals.
Take the blood pressure on the left arm.
The Correct Answer is B
Rationale:
A. Important, but not the priority until urgent causes (like hypoglycemia or hyperglycemia) are ruled out.
B. In a 60-year-old with diabetes or possible symptoms such as dizziness, vision changes, or abnormal vitals, hypoglycemia/hyperglycemia must be ruled out immediately since it can be life-threatening if untreated. This is the priority action.
C. Ear irrigation is not urgent and does not address the potentially serious underlying cause of the patient’s symptoms.
D. The patient’s BP has already been measured. While rechecking may be necessary, it is not the first priority over assessing blood glucose in a potentially unstable diabetic patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Purulent drainage is thick, yellow, green, or brown, indicating infection due to the presence of white blood cells, bacteria, and debris.
B. Sanguineous drainage is primarily blood, appearing bright red and thicker, not watery.
C. Serous drainage is clear or pale yellow and watery, composed mostly of serum, not blood.
D. Serosanguineous drainage is thin and watery with a pink to red color, indicating a mixture of blood and serous fluid. This is commonly seen in healing wounds.
Correct Answer is C
Explanation
A. Warm compresses are not recommended after cataract surgery. The usual teaching involves avoiding pressure, heavy lifting, or bending, not applying compresses.
B. Mild redness or bloodshot appearance is expected after cataract surgery and usually resolves within a few days. This does not require reporting unless accompanied by severe pain, sudden vision loss, or purulent drainage.
C. Sensitivity to light and mild discomfort are expected findings for a couple of days postoperatively as the eye heals.
D. Vision typically improves gradually over several days to weeks as the eye heals, not immediately on the day of surgery.
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