Nokea
The nurse correctly hands the physician which solution?
- A. Povidone-iodine (Betadine)
- B. Gentian violet
- C. Will have to remove my prosthesis for cleaning.
- D. Fluorescein
Correct Answer: D
Rationale: Fluorescein is used to stain the cornea to detect foreign bodies or injuries.
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Which information provided by the nurse will best prepare the client for the caloric test?
- A. Cold water and warm water will be instilled into each of the ears.
- B. You will wear earphones through which sounds are transmitted.
- C. The room will be darkened, and scalp electrodes will be attached to the head.
- D. Your blood will be drawn from a vein and examined microscopically.
Correct Answer: A
Rationale: The caloric test involves instilling water to assess vestibular function.
When the client asks the nurse about the purpose of the eye shield, which explanation is best?
- A. The shield keeps foreign substances out of the eye.
- B. The shield protects the eye from accidental trauma.
- C. The shield reduces rapid eye movement when dreaming.
- D. The shield promotes dilation of the pupil at night.
Correct Answer: B
Rationale: The shield prevents accidental trauma to the healing eye during sleep.
The male client diagnosed with acquired immunodeficiency syndrome (AIDS) states that he has developed a purple-brown spot on his calf. Which action should the nurse do first?
- A. Refer the client to an HCP for a biopsy of the area.
- B. Assess the lesion for size, color, and symmetry.
- C. Discuss end-of-life decisions with the client.
- D. Report the sexually transmitted illness to the health department.
Correct Answer: B
Rationale: Assessing the lesion provides data for suspected Kaposi’s sarcoma, common in AIDS. Biopsy referral, end-of-life discussions, and reporting are secondary.
The nurse must withhold medication administration and notify the physician if which drug is ordered for a client with glaucoma?
- A. Atropine sulfate (Sal-Tropine)
- B. Morphine sulfate (Roxanol)
- C. Magnesium sulfate (Epsom salts)
- D. Ferrous sulfate (Feosol)
Correct Answer: A
Rationale: Atropine can increase intraocular pressure, worsening glaucoma.
The nurse is caring for an elderly female client preoperative for facial reconstruction. Which client problem should the nurse include in the preoperative plan of care?
- A. Loss of self-esteem.
- B. Alteration in comfort.
- C. Ineffective airway clearance.
- D. Impaired communication.
Correct Answer: A
Rationale: Facial reconstruction may impact self-esteem due to appearance concerns. Comfort, airway, and communication are less relevant preoperatively.