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 client's lab culture report is negative for a suspected infection. A test that can correctly identify those who do not have a given disease is:
- A. specific.
- B. sensitive.
- C. negative culture.
- D. marginal finding.
Correct Answer: A
Rationale: A specific test accurately identifies those without the disease (true negatives). Sensitivity identifies those with the disease. The other terms are unrelated to test performance. Safety and Infection Control
The nurse is reinforcing discharge instructions for the parents of a 4-year-old client with heart failure. What statement made by the parents indicates a need for further teaching?
- A. We will hold the dose if our child’s heart rate is above 90/min.
- B. We will not give a second dose if our child vomits after the first dose.
- C. We will not mix the medication with other foods or liquids.
- D. We will report symptoms of nausea and vomiting to our health care provider.
Correct Answer: A
Rationale: Holding heart failure medication (e.g., digoxin) for a heart rate above 90/min is incorrect for a 4-year-old, as their normal heart rate is 80-120/min; the threshold is typically lower (e.g., <60/min). Not repeating a dose after vomiting, avoiding mixing with food, and reporting nausea/vomiting are correct.
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
- A. administer both medications simultaneously.
- B. give the medications sequentially, and flush well between them.
- C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
- D. start one medication now and begin the other medication in 2-4 hours.
Correct Answer: B
Rationale: Ampicillin and gentamicin are pH-incompatible, so they must be given sequentially with thorough flushing to prevent precipitation in the IV line. Simultaneous or delayed administration is inappropriate. Pharmacological Therapies
The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care?
- A. Ask if the client performs breast self-exams
- B. Ask the client about characteristics of vaginal discharge
- C. Determine the date of the client's last menstrual period
- D. Review the client's home blood sugar logs
Correct Answer: C
Rationale: Determining the date of the client's last menstrual period is critical to assess for pregnancy or menopausal changes, which could explain the symptoms and impact diabetes management. Breast self-exams and vaginal discharge characteristics are less urgent, and blood sugar logs, while important, are not directly related to the reported symptoms.
The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?
- A. I will allow my child to have a snack while using the HFCWO vest to encourage cooperation.
- B. I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest.
- C. I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable.
- D. My child will use the HFCWO vest once in the morning, once in the evening, and as needed.
Correct Answer: A
Rationale: Eating during HFCWO vest use can increase the risk of aspiration or reduce therapy effectiveness, indicating a need for further teaching. Bronchodilators during therapy, manual percussion as a backup, and the described frequency are appropriate.