Nokea
A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?
- A. Administer PO analgesic medication
- B. Cover the affected eye with an eye patch
- C. Initiate continuous eye irrigation
- D. Perform a Snellen vision test
Correct Answer: C
Rationale: Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye- containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye
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The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
Which isolation procedure will be followed for secretions and blood?
- A. Respiratory
- B. Standard Precautions
- C. Contact Isolation
- D. Droplet
Correct Answer: B
Rationale: Standard Precautions apply to all body fluids except sweat, including blood and secretions, to reduce transmission risk in all client interactions. Safety and Infection Control
The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased over the past 2 days. Which assessment finding is most concerning?
- A. Client rating left shoulder pain as 4 on a scale of 0-10
- B. Greenish-gray drainage noted on surgical dressing
- C. Productive cough with thick, green sputum
- D. Stiff abdomen with rebound tenderness on palpation
- E. Warm, reddened area around the incision site
Correct Answer: D
Rationale: A stiff abdomen with rebound tenderness suggests peritonitis, a life-threatening complication post-cholecystectomy, requiring immediate intervention. Shoulder pain is common due to referred pain, drainage and incision redness suggest localized infection, and a cough may indicate a respiratory issue, but peritonitis is most urgent.
A young couple asks the nurse what method of contraception they should use. What information is most important for the nurse to have before giving an answer?
- A. The exact age of the couple
- B. The sexual history of both partners
- C. The method they find most acceptable
- D. How soon they want to start a family
Correct Answer: C
Rationale: The couple's preferred contraceptive method ensures adherence and satisfaction, guiding the nurse's recommendations. Age, sexual history, or family planning timeline are secondary.
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.