NCLEX Review - Fundamentals of Nursing Study Guide (51-55)

Welcome to NCLEX Review - Fundamentals of Nursing Study Guide. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck



51. A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which nursing action is required to provide sound care of the client's body?

a) close the eyes and places the bed flat
b) maintains the client in a supine position
c) irrigates the client's eyes with normal saline
d) places wet saline gauze pads on the eyelids and a small ice pack on the gauze pads

52. A nurse is caring for a client receiving parenteral nutrition (PN). Which does the nurse implement to decrease the risk of infection?

a) assesses vital signs at 4-hour intervals
b) administers prophylactic antimicrobial agents
c) checks the solution's label against the prescription
d) uses aseptic technique in handling the PH solution

53. The home care nurse provides medication instructions to a male client. To ensure that the client self-administers his medications safely in the home, the nurse:

a) performs a pill count of each prescription bottle at every home visit
b) instructs the client to double up on a medication when a dose is missed
c) demonstrates the proper procedure for self-administration of medications
d) asks the client to explain and demonstrate self-administration procedures

54. A client asks the home care nurse to witness the client's signature in a living will with the client's attorney in attendance. Which should the nurse implement?

a) decline to witness the signature on the wall
b) sign the will as a witness to the signature only
c) notify the supervisor that a living will is being witnessed
d) sign the will with identifying credentials and employment agency

55. The nurse notes old and new ecchymotic areas on an older client's arms and buttocks upon admission. The client tells the nurse in confidence that her daughter frequently hits her. Which statement should the nurse use in response?

a) I have a legal obligation to report this type of abuse
b) let's get these treated and I will maintain the confidence
c) if this happens again, you must call the emergency department
d) let's talk about ways to prevent your daughter from hitting you






Fundamentals of Nursing Study Guide
Answers and Rationale

51) D

- When a corneal donor dies, the eyes are closed and sterile gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated, and the corneas are usually transplanted within 24 to 48 hours. The head of the bed should be elevated. With the head of the bed elevated, the eyes will likely remain closed. Eye irrigations, if indicated, would be prescribed by the transplant surgeon.

52) D

- Clients receiving PN are at high risk for developing infection because the concentrated glucose solutions are an excellent medium for bacterial growth. The nurse reduces the client's risk of infection by using aseptic technique when handling all equipment and solutions related to the PN infusion. Option A is a reasonable intervention for early detection of infection but does not prevent infection. Prophylactic antibiotics are not indicated for PN infusions and can contribute to the development of secondary infections. The nurse implements option C to ensure that the client receives the correct infusion.

53) D

- To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually, it is not acceptable to double up on missed medication, and conducting a pill count on each visit is unrealistic and disrespectful.

54) A

- Living wills must be written documents and signed by the client. The client's signature either must be witnessed by nonagency individuals or notarized, thus the nurse should decline to sign the will to avoid a conflict of interest. The nurse's signature on the living will testifies to the validity of the client's signature. If the nurse contacts the supervisor, the supervisor should advise the nurse to decline.

55) A

- The nurse should inform the client that nurses cannot maintain confidences about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options C and D delay protective action and place the client at risk for future abuse.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Review - Fundamentals of Nursing Study Guide (1-5)


Or proceed to the next set of questions:

NCLEX Review - Fundamentals of Nursing Study Guide (56-60)

Read More

Eye Correction (NCLEX 71-75)

Welcome to Eye Correction NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


71. A nurse receives a telephone call from a neighbor, who tells the nurse that the spouse accidentally broke a mirror, and a piece of glass flew into the eye. The nurse arrives at the home and finds that a piece of glass is protruding from the victim's eye. The nurse should:

a) remove the piece of glass using a tweezers that was boiled for sterilization purposes
b) apply an eye patch and instruct the victim and spouse to report to the emergency department
c) accompany the victim and spouse to the emergency department
d) flush the eye thoroughly with tap water


72. A client arrives at the emergency department after an eye injury in which an acid used to clean the bricks on a fireplace splashed into his eye. The initial assessment question by the nurse is which of the following?

a) did you bring the container of acid with you?
b) what time did the injury occur?
c) did you flush the eye following the injury?
d) what type of acid caused the injury?

73. A nurse is caring for a client following enucleation. Which of the following assessment findings would indicate the need to notify the physician?

a) bright red drainage on the dressing
b) a respiratory rate of 22 breaths per minute
c) complaints of pain in the affected eye
d) a blood pressure of 138/88 mm Hg

74. A client is being discharged from the ambulatory care unit after cataract removal, and the nurse provides instructions regarding home care. Which of the following should the nurse tell the client?

a) take acetaminophen (Tylenol) if any discomfort occurs
b) sleep on the side that was operated on to promote drainage
c) avoid wearing glasses
d) do not lift anything that weighs more than 20 pounds

75. An ambulatory care nurse provides instructions to a client after a cataract extraction. Which statement by the client indicates a need for further instructions?

a) I need to avoid bending over to pick up items
b) I will sleep on the unoperative side
c) I need to wear an eye shield all the time
d) There is no reason to stay on a special diet






Eye Correction
Answers and Rationale

71) C

- If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The most appropriate action by the nurse from the options presented is to accompany the victim to the emergency department.

72) C

- Emergency care following a chemical burn of the eye includes irrigating the eye immediately with tap water or sterile normal saline or ocular irrigating solution if available. The irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. The initial assessment in this situation should focus on the type of treatment that took place immediately following the injury.

73) A

- If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician because this can indicate hemorrhage. Complaints of pain are expected in the postoperative period. A blood pressure of 138/88 mm Hg is within normal range. A respiratory rate of 22 breaths per minute, although slightly elevated from the normal range, does not warrant physician notification.

74) A

- The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day, and an eye shield is worn at night. Aspirin or medications containing aspirin are not to be administered or taken by the client; the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the side of the body that was operated on because this action will cause edema and increased intraocular pressure. The client is not to lift more than 5 pounds.

75) C

- Postoperatively, cataract extraction clients should be positioned on their backs in semi-Fowler position or on the unoperative side to prevent edema in the surgical site. They need to avoid bending at the waist and other activities that will increase intraocular pressure. A special diet is not necessary following this procedure. The client needs to wear an eye shield at night to prevent injury to the eye during sleep. Eyeglasses or an eye patch may be worn during the day.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Eye Correction NCLEX Questions (1-6)

Read More

Eye Correction (NCLEX 66-70)

Welcome to Eye Correction NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


66. A nursing student is caring for a client in the health care clinic who has been diagnosed with glaucoma. The nursing instructor asks the student to describe the type of medication that will likely be prescribed for the client to treat the eye disorder. Which statement by the student indicates an accurate understanding of the treatment for glaucoma?

a) a miotic agent will lower the pressure in the eye and increase the blood flow to the retina
b) a dilating agent will help dilate the eye to prevent pressure from occurring
c) a cycloplegic will relax the muscles of the eyes and prevent blurred vision
d) a mydriatic agent will help block the responses that are sent to muscles in the eye

67. A clinic nurse has provided instructions to a client with a diagnosis of glaucoma. Which statement by the client indicates an understanding of the treatment plan for glaucoma?

a) I need to restrict my fluid intake to four glasses daily
b) I need to take my eye drops for the rest of my life
c) I can uses salt only for cooking
d) I need to limit my amount of reading to 2 hours a day

68. A nurse is caring for a client with a diagnosis of retinal detachment. The client suddenly complains of a burst of black spots or floaters. The nurse interpret this symptom as:

a) hemorrhage as a result of the detachment
b) an expected finding
c) the need to restrict fluids
d) the need to patch the affected eye

69. A nurse is preparing a plan of care for a client being admitted to the hospital with a diagnosis of retinal detachment. Which of the following will the nurse include in the plan of care?

a) out of bed to ambulate with assistance
b) place an eye patch over the affected eye
c) maintain high-fowler's position
d) restrict visitors

70. A client arrives at the emergency department after a blow to the eye from a softball. The initial nursing action would be to:

a) call a physician to perform a thorough eye examination
b) irrigate the eye with sterile cool water
c) place the client in a supine position on a stretcher
d) apply ice to the affected eye







Eye Correction:
Answers and Rationale

66) A

- Miotics are used to lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of trabecular meshwork. Options B, C, and D all describe actions related to mydriatic medications, which primarily dilate the pupils and relax the ciliary muscles. These options are incorrect and would not be used for the client with glaucoma.

67) B

- The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his life. Limiting fluids or reducing salt intake will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan.

68) A

- Complaint of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment. This is not a normal, expected finding and if it occurs, it indicates hemorrhage. There is no need to restrict fluids. The nurse places an eye patch over the client's affected eye to reduce eye movement, but the patch should have already been in place.

69) B

- The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the physician. Visitors do not need to be restricted.

70) D

- A traumatic injury with a blunt object is treated immediately with the application of ice. The client should receive a thorough eye examination to rule out the presence of other eye injuries, but this is not the initial action. Eye irrigation is not necessarily required for a blunt injury. The supine position would increase the amount of swelling in the eye.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Eye Correction NCLEX Questions (1-6)

Or proceed to the next set of questions:

Eye Correction NCLEX Questions (71-75)

Read More

Eye Health Questions (NCLEX 61-65)

Welcome to NCLEX Eye Health Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


61. A client has undergone surgery to treat glaucoma. The nurse reinforces which home care instruction with the client?

a) wound healing usually takes 16 weeks
b) expect that vision will be permanently impaired to a small degree
c) a shield or eye patch should be worn to protect the eye
d) the sutures are removed after 1 week

62. A client has undergone surgery for cataracts. The nurse instructs the client to call the physician if which of the following occurs?

a) a sudden decrease in vision
b) eye pain relieved by acetaminophen (Tylenol)
c) small amounts of dried matter on the lashes after sleep
d) gradual resolution of eye redness

63. A nurse is caring for a client with arthritis. The client complains of difficulty instilling glaucoma eye drops because of shaking hands caused by the arthritis. Which instruction would the nurse provide to the client to alleviate this problem?

a) keep the drops in the refrigerator so they will thicken and be easier to instill
b) lie down on a bed to instill the eye drops
c) tilt the head straight back to instill the eye drops
d) talk to the physician about the need for eye drops

64. Corrective glasses are prescribed for the client with bilateral aphakia, and the nurse provides instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further instructions?

a) the glasses will correct my peripheral visual field of sight
b) the glasses will magnify my central vision by 30%
c) objects that I look at may be distorted
d) it may be difficult to judge distances when I drive a car

65. A client is brought to the ambulatory care department by her spouse one day following a cataract extraction procedure and is diagnosed with hyphema that occurred as a result of the surgical procedure. The nurse provides which instruction to the client and spouse regarding treatment for the hyphema?

a) resume normal activities because the hyphema will resolve on its own
b) obtain assistance when ambulating
c) return to the ambulatory care department for removal of the intraocular lens implant
d) maintain bedrest and place an eye shield or patch over both eyes







Eye Health Questions
Answers and Rationale

61) C

- After ocular surgery, the client should wear an eye patch or eyeglasses for protection of the eye. Healing takes place in about 6 weeks. Once the postoperative inflammation subsides, the client's vision should return to the preoperative level of acuity. Sutures are usually absorbable.

62) A

- The client should report a noticeable or sudden decrease in vision to the physician. The client is taught to take acetaminophen, which is usually effective in relieving discomfort. The eye may be slightly reddened postoperatively, but this should gradually resolve. Small amounts of dried material may be present on the lashes after sleep. This is expected and should be removed with a warm facecloth.

63) B

- Eye drop regimen is a critical component of treatment for a client with glaucoma to prevent blindness. Clients with arthritis or shaking hands have difficulty instilling their own eye drops. The client is instructed to lie down on a bed or sofa. Tilting the head back can lead to loss of balance. Placing eye drops in a refrigerator should not be done unless specifically prescribed.

64) A

- Corrective glasses, contact lenses, or intraocular lenses correct aphakia (absence of the lens of the eye). Only central vision is corrected with corrective glasses, and peripheral vision is distorted. There is approximately 30% magnification of central vision with corrective glasses. This requires adjustment of daily activities and use of safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car or sitting in a chair.

65) D

- Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bedrest and bilateral eye patching or shielding for 2 to 5 days, during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood.



After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Eye Health Questions (1-6)

Or proceed to the next set of questions:

Eye Health Questions (66-70)

Read More

Eye Health Questions (NCLEX 56-60)

Welcome to NCLEX Eye Health Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


56. A scleral buckling procedure is performed on a client with retinal detachment, and the nurse provides home-care instructions to the client. Which statement by the client indicates a need for further instructions?

a) I need to avoid heavy lifting
b) I need to avoid vigorous activity
c) I need to wear an eye shield during naps and at night
d) I need to clean the eye daily with sterile water ad a clean washcloth

57. The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family which of the following about positioning during the postoperative period?

a) sleep only on the left side
b) sleep on the right side or the back
c) bend below the waist as often as you are able
d) lower the head between the knees three times a day


58. A client has undergone surgery for glaucoma. The nurse provides which discharge instructions to the client?

a) the sutures are removed after 1 week
b) wound healing usually takes 12 weeks
c) expect that vision will be permanently impaired
d) a shield or eye patch should be worn to protect the eye


59. A client has undergone surgery for cataracts. The nurse instructs the client to call the physician for which of the following complaints?

a) a sudden decrease in vision
b) a gradual resolution of eye redness
c) eye pain relieved by acetaminophen (Tylenol)
d) small amounts of dried matter on the eyelashes after sleep

60. A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further instruction?

a) I can use an ophthalmic analgesic ointment at night if I have eye discomfort
b) I do not need to be concerned about spreading this infection to others in my family
c) I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye
d) I should perform a saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present






Eye Health Questions
Answers and Rationale

56) D

- In a scleral buckling procedure, the sclera is compressed from the outside by Silastic sponges or silicone bands that are sutured in place permanently. In addition, an intraocular injection of air, a gas bubble, or both may be used to apply pressure on the retina from the inside of the eye to hold the retina in place. If an air or gas bubble has been injected, it may take several weeks to be absorbed. Vigorous activities and heavy lifting are avoided. An eye shield or glasses should be worn during the day, and a shield should be worn during naps and at night. The client is instructed to clean the eye with warm tap water using a clean washcloth.

57) B

- After cataract surgery, the client should not sleep on the operative side. The client should also avoid bending below the level of the waist or lowering the head, because these actions will increase intraocular pressure.

58) D

- After ocular surgery, the client should wear an eye patch or eyeglasses for the protection of the eye. Healing takes place in about 6 weeks. When the postoperative inflammation subsides, the client's vision should return to the preoperative level of acuity. Sutures are usually absorbable.

59) A

- The client should report a noticeable or sudden decrease in vision to the physician. The eye may be slightly reddened postoperatively, but this should gradually resolve. The client is taught to take acetaminophen, which is usually effective for relieving discomfort. Small amounts of dried material may be present on the lashes after sleep; this is expected and should be removed with a warm facecloth.

60) B

- Conjunctivitis is highly contagious. Antibiotic drops are usually administered four times a day. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed. When purulent discharge is present, saline eye irrigations or applications of warm compresses to the eye may be necessary before instilling the medication.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Eye Health Questions (1-6)

Or proceed to the next set of questions:

Eye Health Questions (61-65)

Read More

Eye Health Questions (NCLEX 51-55)

Welcome to NCLEX Eye Health Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

Complete NCLEX Study Materials

Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck


51. The nurse has an order to administer two opthalmic medications to the client who has undergone eye surgery. The nurse waits how many minutes after administering the first medication before giving the second?

a) 1 to 2
b) 3 to 5
c) 8 to 10
d) it is not necessary to wait; the second medication can be administered immediately

52. The nurse is assigned to care for a client who has just undergone cataract surgery. The nurse plans to instruct the client that which of the following activities is permitted in the postoperative period?

a) bending over
b) lifting objects
c) coughing exercises
d) watching television

53. During a routine visit to the physician's office for monitoring of diabetic control, an older client with diabetes mellitus complains to the nurse of vision changes. The client describes blurring of vision with difficulty in reading and with driving at night. Given the history, the nurse interprets that the client is probably developing:

a) cataracts
b) glaucoma
c) papilledema
d) detached retina

54. A client arrives at the emergency room with a chemical burn of the left eye. The nurse immediately:

a) applies a light bandage to the eye
b) performs an assessment on the client
c) applies a cold compress to the injured eye
d) flushes the eye continuously with a sterile solution

55. The home care nurse visits an older client with arthritis. The client complains of difficulty instilling glaucoma eye drops because of shaking hands caused by the arthritis. Which instruction should the nurse plans to provide to the client to alleviate this problem?

a) tilt the head back to instill the eye drops
b) lie down on a bed or sofa to instill the eye drops
c) a family member will have to instill the eye drops
d) keep the eye drops in the refrigerator so that they will thicken and be easier to instill







Eye Health Questions
Answers and Rationale

51) B

- The nurse waits 3 to 5 minutes between administration of the two separate ophthalmic medications. This allows for adequate ocular absorption of the medication and prevents the second medication from flushing out the first.

52) D

- The client is taught to avoid activities that raise intraocular pressure and could cause complications in the postoperative period. The client is also taught to avoid activities that cause rapid eye movements that are irritating in the presence of postoperative inflammation. For these reasons, the client is taught to avoid bending over, lifting heavy objects, straining, sneezing, coughing, making sudden movements, or reading. Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure.

53) A

- Although the incidence of cataracts increases with age, the older client with diabetes mellitus is at greater risk for developing cataracts. The most frequent complaint is blurred vision that is not accompanied by pain. The client may also experience difficulty with reading, night driving, and glare. Options B, C, and D are not directly associated with this client's history or complaints.

54) D

- When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Performing an assessment may be helpful but is not the priority action. Applying compresses or bandages is incorrect, because they do not rid the eye of the damaging chemical. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.

55) B

- Older clients with arthritis or shaking hands have difficulty instilling their own eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops. Tilting the head back can lead to a loss of balance. Eye drop regimens for glaucoma require accurate timing, and it is unreasonable to expect a family member to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Eye Health Questions (1-6)

Or proceed to the next set of questions:

Eye Health Questions (56-60)

Read More

Endocrine NCLEX Questions (76-80)

Welcome to Endocrine NCLEX Questions. Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. 
Good Luck.


76. A client with a diagnosis of Cushing's syndrome is undergoing a dexamethasone suppression test. The nurse plans to implement which steps during this test?

a ) collect a 24-hour urine specimen to measure serum cortisol levels
b) administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning
c) draw blood samples before and after exercise to evaluate the effect of exercise on serum cortisol levels
d) administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to measure serum cortisol levels


77. The nurse is caring for a client with type 1 diabetes mellitus. Which of the following laboratory results would indicate a potential complication associated with this disorder?

a) ketonuria
b) potassium: 4.2 mEq
c) blood glucose: 112 mg/dL
d) blood urea nitrogen (BUN): 18 mg/dL

78. Endocrine NCLEX Questions about the nurse who is employed in a diabetes mellitus clinic is caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy?

a) if my blood glucose is elevated, I can bolus myself with additional insulin as ordered
b) I'll need to check my blood glucose before meals in case I need a premeal insulin anymore
c) I still need to follow a diet and exercise plan even though I don't inject myself daily anymore
d) now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis ever happening again

79. A client with Grave's disease has exopthalmos and is experiencing photophobia. Which of the following nursing interventions would best assist the client with this problem?

a) obtain dark glasses for the client
b) lubricate the eyes with tap water every 2 to 4 hours
c) administer methimazole (Tapazole) every 8 hours around the clock
d) instruct the client to avoid straining or heavy lifting because this can increase eye pressure

80. The nurse is completing a health history on a client with diabetes mellitus who has been taking insulin for many years. At present the client states that he is experiencing periods of hypoglycemia followed by periods of hyperglycemia. The most likely cause for this occurrence is which of following?

a) eating snacks between meals
b) initiating the use of the insulin pump
c) injecting insulin at a site of lipodystrophy
d) adjusting insulin according to blood glucose levels





Endocrine NCLEX Questions
Answers and Rationale

76) B

- The dexamethasone suppression test is performed to evaluate the function of the adrenal cortex. The procedure for this test is to administer 1 mg of dexamethasone at 11:00 PM to suppress ACTH formation and then to obtain 8:00 AM serum cortisol levels on the following day.

77) A

- Ketonuria is an abnormal finding in the client with diabetes mellitus indicating ketosis. Ketosis is a metabolic effect from the lack of insulin on fat metabolism and occurs in type 1 diabetes mellitus. It is associated with the severe complication of diabetic ketoacidosis (hyperglycemia, ketosis, and acidosis). Options B, C, and D are all normal laboratory findings.

78) D

- Endocrine NCLEX Questions Rationale: Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump. Options A, B, and C are accurate regarding the use of the insulin pump.

79) A

- Medical therapy for Graves' disease does not help alleviate the clinical manifestation of exophthalmos. Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling around the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. Methimazole inhibits the synthesis of thyroid hormone and is used to treat hyperthyroidism but will not alleviate exophthalmos or photophobia. There is no need to avoid straining with exophthalmos.

80) C

- Lipodystrophy, specifically lipohypertrophy, involves swelling of the fat at the site of repeated injections. This can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been on insulin for many years, this is the most likely cause of poor control. Options A, B, and D are appropriate techniques to use in order to regulate blood glucose levels.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Endocrine NCLEX Questions (1-7)

Read More