Page 2615 - Saunders Comprehensive Review For NCLEX-RN

Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Skills: Tube care
Health Problem: N/A
Priority Concepts: Gas Exchange; Safety
Reference: Lewis et al. (2017), pp. 487-488.

935. Answer: 1

Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity
are associated with the development of glaucoma. Options 2, 3, and 4 do not identify
risk factors associated with this eye disorder.
Test-Taking Strategy: Focus on the subject, a risk factor associated with
glaucoma. Recall that glaucoma is associated with increased pressure in the eye. This
will assist to direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Glaucoma
Priority Concepts: Health Promotion; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 972.

936. Answer: 4

Rationale: 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. Therefore, reading and watching television are not
allowed. The client’s position is prescribed by the primary health care provider;
normally, the prescription is to lie flat.
Test-Taking Strategy: Focus on the subject, retinal detachment. Remember that
the eye needs to be protected and rested. This should direct you to the correct
option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Retinal detachment
Priority Concepts: Sensory Perception; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 980.

937. Answer: 3

Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli

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