Nokea
The emergency department (ED) nurse is caring for a client with a head injury following a car accident. After a hyphema has been noted, the nurse should position the client
- A. Supine.
- B. Semi-Fowler's.
- C. Lateral on the affected side.
- D. Lateral on the unaffected side.
Correct Answer: B
Rationale: Semi-Fowler’s position (30-45 degrees) reduces intraocular pressure in hyphema, preventing complications. Supine or lateral positions may increase pressure.
You may also like to solve these questions
The nurse is caring for a client who is 24 hours postoperative following a left total knee replacement. Which assessment data would indicate that the client is ready for discharge?
- A. Pulse (P) 102, RR 18, BP 104/72 mm Hg
- B. Urine output of 200 mL in the past 8 hours
- C. Lung bases are clear upon auscultation
- D. The client rates left knee pain as 8/10 on the Numerical Rating Scale
Correct Answer: C
Rationale: Clear lung bases indicate no respiratory complications, such as pneumonia, which is critical for discharge readiness. A pulse of 102 and low blood pressure (104/72 mm Hg) suggest possible instability, requiring further evaluation. Low urine output (200 mL/8 hours) indicates potential renal issues, and severe pain (8/10) suggests inadequate pain control, both contraindicating discharge.
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
A client requests to change rooms after overhearing that their roommate is positive for the human immunodeficiency virus (HIV). The nurse should take which appropriate action?
- A. Relocate the client to a private room
- B. Ask the client to elaborate on their concern
- C. Notify the risk manager of the request
- D. Place an additional divider in-between the two beds
Correct Answer: B
Rationale: Asking the client to elaborate addresses potential misconceptions about HIV transmission, which occurs via blood or bodily fluids, not casual contact. Relocation, risk management, or dividers are unnecessary.
The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply.
- A. Pulmonary tuberculosis
- B. Pertussis
- C. Rubeola
- D. Hepatitis A
- E. Rubella
Correct Answer: A,C
Rationale: Pulmonary TB and rubeola (measles) require airborne precautions due to airborne transmission. Pertussis and rubella require droplet precautions, and Hepatitis A is contact-based.
The nurse is caring for a client with right-sided weakness. When transferring the client from the bed to a wheelchair, which action should the nurse perform?
- A. Place the wheelchair as close to the bed as possible on the client's unaffected side
- B. Place the wheelchair as close to the bed as possible on the client's affected side.
- C. Remove any nonskid slippers from the client's feet
- D. Gently pull on the client's arm to assist them to the side of the bed
Correct Answer: A
Rationale: Placing the wheelchair on the unaffected side (left) allows the client to pivot on their stronger side. Affected-side placement, removing slippers, or pulling the arm risk injury or falls.