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The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.
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An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
The nurse is caring for a client with a seizure disorder. Which of the following seizure precautions should the nurse implement? Select all that apply.
- A. Apply pads to the side rails.
- B. Remove all linen from the bed.
- C. Set up bedside suction equipment
- D. Prepare to apply soft limb restraints.
- E. Ensure supplemental oxygen is available.
Correct Answer: A,C,E
Rationale: Padded rails prevent injury. Suction clears airways. Oxygen supports breathing. Removing linen is unnecessary, and restraints are a last resort due to injury risk.
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to the client on what possible adverse effect?
- A. Hypernatremia
- B. Sexual dysfunction
- C. Urinary retention
- D. Weight loss
Correct Answer: B
Rationale: Sertraline commonly causes sexual dysfunction, a significant side effect. Hypernatremia , urinary retention , and weight loss are less common.
Which of the following tasks can the nurse assign to an unlicensed assistive personnel (UAP)?
- A. assisting a client with ambulating to the bathroom for the first time following surgery
- B. expiated client with dementia who has a serum glucose level of 70 mg/dL (3.9 mmol/L)
- C. explaining why incentive spirometer use is important to a client with postoperative pneumonia
- D. taking vital signs every 15 minutes on a client who was just transferred from the postanesthesia recovery unit
Correct Answer: D
Rationale: Taking vital signs is within UAP scope. First-time ambulation , hypoglycemia , and teaching require nursing judgment.