Nokea
A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan to take?
- A. Apply pressure to the client’s nasolacrimal duct after instillation
- B. Clean the client's eye from the outer canthus to the inner canthus before instillation
- C. Ask the client to tightly squeeze their eyes shut after the instillation
- D. Instill the ophthalmic medication directly on the client's cornea
Correct Answer: A
Rationale: The correct answer is A: Apply pressure to the client’s nasolacrimal duct after instillation. This action helps prevent systemic absorption of the medication and decreases the risk of side effects. By gently pressing on the nasolacrimal duct, the nurse can reduce the systemic absorption of the medication and promote its local effects. This technique is crucial for ophthalmic medications to work effectively and minimize adverse reactions.
Choice B is incorrect because cleaning the eye from outer to inner canthus can introduce contaminants into the eye, increasing the risk of infection. Choice C is incorrect as tightly squeezing the eyes shut can also lead to systemic absorption of the medication. Choice D is incorrect as instilling the medication directly onto the cornea can be harmful and may not distribute the medication effectively.
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A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?
- A. Assessment
- B. Planning
- C. Evaluation
- D. Analysis
Correct Answer: B
Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse collaborates with other healthcare professionals to develop a comprehensive discharge plan for the postoperative client. This involves setting goals, determining interventions, and outlining the necessary resources for a smooth transition from the hospital to home care. Assessment (choice A) involves collecting data, evaluation (choice C) involves determining the effectiveness of the plan, and analysis (choice D) involves breaking down information. In this scenario, the nurse is actively involved in creating a structured plan for the client's discharge, making choice B the correct answer.
A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Holds their hands below elbows while rinsing off soap
- B. Uses hot water to wash their hands
- C. Turns off the faucet with their hands
- D. Washes their hands for 10 seconds
Correct Answer: A
Rationale: The correct answer is A because holding hands below elbows while rinsing off soap prevents contamination of clean hands by dirty water. This action ensures proper hand hygiene by maintaining a unidirectional flow of water from clean to dirty areas. Choice B using hot water is incorrect as it may cause skin irritation. Choice C turning off the faucet with hands can reintroduce contamination. Choice D washing hands for only 10 seconds is insufficient for effective hand hygiene.
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?
- A. Uncomplicated grief
- B. Prolonged grief
- C. Anticipatory grief
- D. Disenfranchised grief
Correct Answer: B
Rationale: The correct answer is B: Prolonged grief. This is because the client is still struggling to accept the loss after 3 years, which is indicative of prolonged grief. Uncomplicated grief (Choice A) typically resolves within a reasonable timeframe. Anticipatory grief (Choice C) occurs before the actual loss. Disenfranchised grief (Choice D) is when the individual's grief is not openly acknowledged or socially supported. In this scenario, the client's grief extends beyond the normal grieving process, indicating prolonged grief.
A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first?
- A. Assist the client into a standing position
- B. Check the blood pressure with the client in a supine position
- C. Determine the client's blood pressure 1 min after each position change
- D. Place the client in a sitting position
Correct Answer: B
Rationale: The correct answer is B: Check the blood pressure with the client in a supine position. This is the first action the nurse should take because it establishes the baseline blood pressure of the client in a resting position. Orthostatic hypotension is characterized by a drop in blood pressure upon standing. By measuring the blood pressure in a supine position first, the nurse can accurately assess the extent of the blood pressure change when the client stands up.
Choices A, C, and D are incorrect because they involve positioning changes before establishing the baseline blood pressure. It is crucial to first determine the baseline blood pressure to accurately diagnose orthostatic hypotension. Choice A (Assist the client into a standing position) and D (Place the client in a sitting position) may exacerbate the client's symptoms if orthostatic hypotension is present. Choice C (Determine the client's blood pressure 1 min after each position change) is premature without knowing the baseline blood pressure.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.