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
You may also like to solve these questions
A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is
- A. start a peripheral IV
- B. initiate closed-chest massage
- C. establish an airway
- D. obtain the crash cart
Correct Answer: C
Rationale: Establishing an open airway is always the primary objective in a cardiopulmonary arrest.
A 15-year-old client with iron deficiency anemia and a ruptured ectopic pregnancy needs a blood transfusion prior to surgery. The client's mother is a Jehovah's Witness and refuses to sign the blood permit. Which nursing action is most appropriate?
- A. Give the blood without the mother's permission.
- B. Coax the mother to change her mind.
- C. Allow the client to sign the permit.
- D. Notify the physician of the mother's refusal.
Correct Answer: D
Rationale: The nurse must respect the mother's refusal due to religious beliefs and notify the physician to discuss alternatives or legal options, such as court intervention for a minor in a life-threatening situation. Giving blood without permission is unethical and illegal. Coaxing may be coercive, and a 15-year-old typically cannot provide legal consent.
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
- A. High risk for infection related to vomiting
- B. Altered family processes related to chronic illness
- C. Fluid volume deficit related to vomiting
- D. Risk for aspiration related to loss of consciousness
Correct Answer: D
Rationale: The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.
The nurse is talking with a client with obsessive-compulsive disorder. When the client performs ritualistic behaviors, the nurse should recognize that the client
- A. is hearing voices
- B. is trying to control feelings of anger
- C. has an intense desire to control the environment
Correct Answer: C
Rationale: Ritualistic behaviors in OCD are driven by an intense need to control the environment or reduce anxiety through repetitive actions. They are not related to hearing voices or controlling anger, which are more associated with other disorders.
The nurse is preparing to administer an acetaminophen suppository to a 4-year-old client. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client in the side-lying position.
- B. Guide the suppository along the rectal wall.
- C. Use a gloved index finger to insert the suppository.
- D. Advance the suppository no further than the external sphincter.
- E. Hold the client's buttocks together firmly after inserting the suppository.
Correct Answer: A,C,E
Rationale: The side-lying position facilitates insertion, a gloved finger ensures hygiene, and holding buttocks prevents expulsion. Guiding along the rectal wall is unnecessary, and the suppository should be inserted beyond the external sphincter for absorption.