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Q1. What finding does the nurse anticipate when assessing a client with a new
diagnosis of glaucoma?
A. Seeing "shooting stars"
B. Decrease in central vision
C. Gradual loss of visual fields
D. Abrupt onset of excruciating pain
Correct Answer: C
Explanation: Primary open-angle glaucoma typically causes a gradual, painless loss
of peripheral vision (visual fields) due to increased intraocular pressure damaging
the optic nerve. Central vision is usually preserved until late in the disease.
Q2. Death of bone tissue can occur when the blood supply to the bone is
disrupted. What is this complication called?
A. Delayed union
B. Complex regional pain syndrome
C. Reflex sympathetic dystrophy
D. Avascular necrosis
Correct Answer: D
Explanation: Avascular necrosis (AVN) is the death of bone tissue resulting from
interruption of blood supply. It is a serious complication that can occur following
fractures, especially of the femoral head or scaphoid bone.
Q3. What is the priority nursing diagnosis for a client with immobility?
A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine
, position
C. Risk for impaired skin integrity as evidenced by pressure over bony
prominences
D. Risk for disuse syndrome as evidenced by immobility
Correct Answer: B
Explanation: Respiratory complications such as atelectasis and pneumonia pose
immediate life-threatening risks in immobile patients. Ineffective breathing
pattern is prioritized over constipation or skin integrity because hypoxia can
rapidly lead to deterioration.
Q4. What is the priority intervention when caring for a client in Buck's traction?
A. Change the size of the traction weights PRN as needed
B. Discontinue the traction as soon as the client has pain relief
C. Allow the traction weights to rest on the floor
D. Assess skin integrity
Correct Answer: D
Explanation: Buck's traction (skin traction) requires regular skin integrity
assessment beneath the traction boot to prevent skin breakdown, pressure
injuries, and nerve damage. Weights should never be adjusted, discontinued, or
allowed to rest on the floor by nursing staff.
Q5. A client has a fractured right arm. Which of these should the nurse complete
first?
A. Apply ice to the fracture site
B. Administer pain medications
C. Remove the client's bracelet and rings from the right arm
D. Send the client to radiology for an x-ray
Correct Answer: C
Explanation: Jewelry must be removed immediately from an injured extremity
before swelling occurs. Once edema develops, rings and bracelets can become