Nokea
The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?
- A. Lavage through a small-bore nasogastric tube
- B. Place client in Trendelenburg position during lavage
- C. Prepare intubation and suction supplies at the bedside
- D. Wait an hour after gastric decompression to initiate lavage
Correct Answer: C
Rationale: Preparing intubation and suction supplies ensures readiness for airway protection, as gastric lavage carries a risk of aspiration. Small-bore tubes are inadequate for lavage, Trendelenburg increases aspiration risk, and waiting an hour delays urgent treatment.
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The nurse is giving instructions to a group of women about breast self-examination. Which statement indicates that the client needs more instruction about the procedure?
- A. I will perform the exam every month after my period.'
- B. I should do the exam both standing and lying down.'
- C. Some ridges are normal in my breast.'
- D. I will do the breast self-exam every month until menopause.'
Correct Answer: D
Rationale: Breast self-exams should continue lifelong, not stop at menopause, as breast cancer risk persists. Other statements reflect correct technique.
The nurse is caring for a client who has oral candidiasis. The nurse should expect that the client will be prescribed
- A. nystatin
- B. acyclovir
- C. mupirocin
- D. griseofulvin
Correct Answer: A
Rationale: Nystatin is an antifungal medication specifically used to treat oral candidiasis (thrush). Acyclovir treats viral infections, mupirocin is for bacterial skin infections, and griseofulvin treats fungal skin infections, not oral candidiasis.
The nurse is caring for a client diagnosed with generalized anxiety disorder. What behavior demonstrates that the client is building resilience toward improving anxiety symptoms?
- A. Avoids anxiety-producing situations
- B. Identifies anxiety-reducing triggers
- C. Practices stress-reduction techniques daily
- D. Relies on medication to manage symptoms
Correct Answer: C
Rationale: Practicing stress-reduction techniques daily, such as mindfulness or deep breathing, actively builds resilience by equipping the client with tools to manage anxiety symptoms effectively. Avoiding situations may reinforce anxiety, identifying triggers is helpful but less proactive, and relying solely on medication does not foster long-term resilience.
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
A nurse is making a home visit when a fire starts in the client’s kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply.
- A. Aim the nozzle at the base of the fire
- B. Pull out the pin on the handle
- C. Shake the canister prior to use
- D. Squeeze the handle to spray
- E. Sweep the spray from side to side
Correct Answer: A,B,D,E
Rationale: Using the PASS technique (Pull, Aim, Squeeze, Sweep), the nurse should pull the pin, aim at the fire’s base, squeeze the handle, and sweep side to side to extinguish the fire. Shaking the canister is not required and may delay response.