Nokea
A patient presents at the ED after receiving a chemical burn to the eye. What would be the nurses initial intervention for this patient?
- A. Generously flush the affected eye with a dilute antibiotic solution.
- B. Generously flush the affected eye with normal saline or water.
- C. Apply a patch to the affected eye.
- D. Apply direct pressure to the affected eye.
Correct Answer: B
Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.
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The nurse is discharging a patient home after mastoid surgery. What should the nurse include in discharge teaching?
- A. Try to induce a sneeze every 4 hours to equalize pressure.
- B. Be sure to exercise to reduce fatigue.
- C. Avoid sleeping in a side-lying position.
- D. Dont blow your nose for 2 to 3 weeks.
Correct Answer: D
Rationale: The correct answer is D: "Don't blow your nose for 2 to 3 weeks." After mastoid surgery, blowing the nose can increase pressure in the surgical area and disrupt healing. Here's the rationale:
1. Blowing the nose can increase pressure in the surgical area and lead to complications.
2. Avoiding blowing the nose helps prevent infection and reduces the risk of damaging the surgical site.
3. It is essential to follow this instruction to promote proper healing and reduce the chances of postoperative complications.
In summary, the other choices are incorrect because inducing a sneeze, exercising, and avoiding side-lying position do not directly relate to the specific care needs after mastoid surgery.
A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle should guide the nurses choice of educational interventions?
- A. Many older adults do not see themselves as being at risk for HIV infection.
- B. Many older adults are not aware of the difference between HIV and AIDS.
- C. Older adults tend to have more sex partners than younger adults.
- D. Older adults have the highest incidence of intravenous drug use.
Correct Answer: A
Rationale: The correct answer is A because it addresses the key issue of perception of risk among older adults. Many older adults may not perceive themselves as being at risk for HIV infection due to misconceptions or lack of awareness. This principle guides the nurse to tailor educational interventions to address this specific barrier. Choices B, C, and D are incorrect as they do not directly address the perception of risk among older adults. Older adults' awareness of HIV/AIDS, number of sex partners, or incidence of intravenous drug use are not the primary factors influencing their perception of HIV risk.
A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
- A. An incisional biopsy is performed because its known to be less painful and more accurate than other forms of testing.
- B. An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
- C. An incisional biopsy is performed to assess the potential for recovery from a mastectomy.
- D. An incisional biopsy is performed on patients who are younger than the age of 40 and who are otherwise healthy.
Correct Answer: B
Rationale: The correct answer is B because an incisional biopsy is typically performed to confirm a diagnosis by obtaining a sample of the tissue in question. This allows for further analysis through special studies to determine the best course of treatment. The other choices are incorrect because:
A: The reason for performing an incisional biopsy is not primarily based on pain or accuracy comparisons with other testing methods.
C: An incisional biopsy is not done to assess potential recovery from a mastectomy but rather to diagnose the nature of the mass.
D: Age and general health status are not sole criteria for determining the need for an incisional biopsy.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the nurse take when feeding this patient?
- A. Position in semi-Fowler’s.
- B. Flex head with chin tuck.
- C. Place food on left side.
- D. Offer fruit juice.
Correct Answer: B
Rationale: The correct answer is B: Flex head with chin tuck. This position helps prevent aspiration by closing off the airway during swallowing. Flexing the head and tucking the chin promotes safe swallowing and reduces the risk of choking. Placing food on the left side (choice C) is not relevant to addressing the patient's symptoms. Positioning in semi-Fowler's (choice A) may not directly address the swallowing difficulty. Offering fruit juice (choice D) does not address the patient's specific feeding needs and may not be safe if the patient has swallowing difficulties.
A nurse is providing care to a group of patients.Which patient will the nurse seefirst?
- A. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence
- B. A patient with reflex incontinence with elevated blood pressure and pulse rate
- C. A patient with an indwelling catheter that has stool on the catheter tubing
- D. A patient who has just voided and needs a postvoid residual test
Correct Answer: B
Rationale: The correct answer is B because reflex incontinence with elevated blood pressure and pulse rate indicates a potentially urgent medical situation that requires immediate attention to address the underlying cause. This patient may be at risk for a serious medical event such as autonomic dysreflexia, which requires prompt intervention.
Choice A is incorrect because urge incontinence does not pose an immediate threat to the patient's health compared to the urgent medical situation presented in choice B.
Choice C is incorrect because while stool on the catheter tubing may indicate the need for intervention, it is not as time-sensitive as the situation presented in choice B.
Choice D is incorrect because the patient who has just voided and needs a postvoid residual test does not have any urgent medical issues that require immediate attention compared to the patient with reflex incontinence and elevated vital signs.