Correct Answer: D

The patient would be considered legally blind if the result of the Snellen chart test is 20/200 vision. This means that the patient is able to read at 20 feet what a person with normal vision can read at 200 feet. Legal blindness is defined as 20/200 or less with corrected vision or visual acuity of less than 20 degrees of the visual field in the better eye.

Correct Answer: B

The normal intraocular pressure of the eye is 10 to 21 mm Hg. The test used to measure intraocular pressure is called a tonometry. This is how glaucoma is diagnosed. A patient with glaucoma would have an intraocular pressure of 30 to 70 mm Hg.

Correct Answer: A

The patient should not sleep on the right side following surgery. The patient should be placed in a semi-Fowler position to minimize edema and intraocular pressure. The patient should wear glasses and a protective shield over the affected eye.

Correct Answer: B

The nurse would prepare 15 ml of potassium chloride.

Desired dose: 30 mEq

Available concentration: 40 mEq (Units) per 20 mL (Volume)

Correct Answer: B

Making decisions for the family and patient would not encourage them to have effective communication. It is important to encourage the patient and the family to express their feeling and anger if they need to. Spiritual practices are also a very important part of a patient and family's dying process.

Correct Answer: A

Slander is when something untrue is said about a person that results in injury to that person's good name. Libel would be when something untrue is written about a person that results in injury to the person's good name. The nursing assistant was spreading gossip, not fact, about the secretary, leading to injury to her good name.

Correct Answer: B

The nurse who has never had chicken pox should not be assigned to this patient. Herpes zoster is caused by the same virus that causes chicken pox; therefore, assigning this nurse to this patient would increase her chances of contracting chicken pox from the patient.

Correct Answer: A

Remain with the patient to prevent the patient from becoming overwhelmed and feeling abandoned. The primary focus of the nurse would be to put the patient at ease. It would not be possible to teach the patient to deep breathe or get them to talk until the anxiety has decreased. It would be okay to place the patient in a quiet room as long as you remain with them.

Correct Answer: D

Weight is a good indication of this patient's fluid loss or gain. One kilogram of weight represents one liter of fluid loss or gain, which makes this a very reliable source for dehydration.

Correct Answer: D

The patient with emphysema would be able to enhance their breathing by sitting on the side of the bed and leaning on an overbed table. Other effective positions for the patient would be resting the elbows on the knees and standing while leaning against a wall.

Correct Answer: C

The clinical manifestation that the nurse would most likely see with a pulmonary embolus is dyspnea. Other clinical manifestations that the nurse might see include tachypnea, tachycardia and chest pain. This is a medical emergency, and the physician should be notified immediately if pulmonary embolus is suspected.

Correct Answer: C

The patient is displaying all the symptoms of fluid overload. If the patient were experiencing a transfusion reaction, there would also be itching and a rash. Bacteremia would lead to the patient having a fever. Fluid overload is the best answer due to the crackles in the lungs indicating fluid has become a problem.

Correct Answer: B

The nurse would want to monitor the patient for a prolonged expiratory phase. The allergic reaction would lead to air trapping and alveoli distention that occurs as a result of an anaphylactic response. Respiratory rate will be within normal limits, and wheezing occurs on expiration due to constricted bronchi.

Correct Answer: B

The nurse would want to assess the uterus every 15 minutes to prevent early postpartum hemorrhage. Early detection of a boggy uterus will allow for interventions to prevent postpartum hemorrhage. Other choices are not appropriate in preventing postpartum hemorrhage.

Correct Answer: D

Alcohol abuse leads to decreased desire for sex and decreased ability to perform. The most common forms of sexual dysfunction with alcohol abuse are decreased pleasure, decreased ability to perform, decreased sexual arousal and anxiety about performance.