Nokea
During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?
- A. Wearing gloves during the procedure
- B. Using a sterile solution
- C. Irrigating from the inner to the outer canthus
- D. Positioning the client's head properly
Correct Answer: A
Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.
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A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct Answer: B
Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.
A client with rheumatoid arthritis is prescribed methotrexate. What information should the LPN include when teaching the client about this medication?
- A. Avoid exposure to sunlight.
- B. Take the medication with food.
- C. Increase fluid intake while on this medication.
- D. Report any signs of infection to the healthcare provider immediately.
Correct Answer: D
Rationale: The correct answer is D: 'Report any signs of infection to the healthcare provider immediately.' Methotrexate is an immunosuppressant medication commonly used to treat rheumatoid arthritis. It can lower the immune system's ability to fight infections, making it crucial for clients to promptly report any signs of infection to prevent serious complications. Choices A, B, and C are incorrect because avoiding sunlight, taking the medication with food, and increasing fluid intake are not specific to methotrexate therapy and are not primary concerns associated with this medication.
The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?
- A. Using waxed floss helps prevent bleeding
- B. Flossing removes plaque and tartar from the teeth
- C. Flossing at least 3 times a day is beneficial
- D. Applying toothpaste before flossing is harmful
Correct Answer: B
Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.
A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Encourage the client to increase fluid intake.
- B. Monitor the client's blood glucose level.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: B
Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.
A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview of cardiac rehabilitation
- C. Medication and diet guidelines
- D. Activity and rest guidelines
Correct Answer: A
Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.