Page 1965 - Saunders Comprehensive Review For NCLEX-RN

2. Continue to monitor the drainage.
3. Notify the primary health care provider (PHCP).
4. Mark the drainage on the dressing and monitor for any increase in
bleeding.
686. A woman was working in her garden. She accidentally sprayed insecticide
into her right eye. She calls the emergency department, frantic and screaming
for help. The nurse should instruct the woman to take which immediate
action?
1. Irrigate the eyes with water.
2. Come to the emergency department.
3. Call the primary health care provider (PHCP).
4. Irrigate the eyes with diluted hydrogen peroxide.
687. The nurse is preparing a teaching plan for a client who had a cataract
extraction with intraocular implantation. Which home care measures should
the nurse include in the plan? Select all that apply.

1. Avoid activities that require bending over.

2. Contact the surgeon if eye scratchiness occurs.

3. Take acetaminophen for minor eye discomfort.

4. Expect episodes of sudden severe pain in the eye.

5. Place an eye shield on the surgical eye at bedtime.

6. Contact the surgeon if a decrease in visual acuity occurs.
688. Tonometry is performed on a client with a suspected diagnosis of glaucoma.
The nurse looks at the documented test results and notes an intraocular
pressure (IOP) value of 23. What should be the nurse’s initial action?
1. Apply normal saline drops.
2. Note the time of day the test was done.
3. Contact the primary health care provider (PHCP).
4. Instruct the client to sleep with the head of the bed flat.
689. The nurse is caring for a client following craniotomy for removal of an
acoustic neuroma. Assessment of which cranial nerve would identify a
complication specifically associated with this surgery?
1. Cranial nerve I, olfactory
2. Cranial nerve IV, trochlear
3. Cranial nerve III, oculomotor
4. Cranial nerve VII, facial nerve
690. The nurse notes that the primary health care provider has documented a
diagnosis of presbycusis on a client’s chart. Based on this information, what
action should the nurse take?
1. Speak loudly but mumble or slur the words.
2. Speak loudly and clearly while facing the client.
3. Speak at normal tone and pitch, slowly and clearly.
4. Speak loudly and directly into the client’s affected ear.
691. A client with Meniere’s disease is experiencing severe vertigo. Which
instruction should the nurse give to the client to assist in controlling the

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