Nokea
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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What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct?
- A. It is to observe reactive service and product problem solving
- B. Improvement of the processes in a proactive, preventive mode is paramount
- C. A chart audits to find to the process in a proactive, preventive mode is paramount
- D. A flow chart to organize daily tasks is critical to the initial stages
Correct Answer: B
Rationale: Improvement of the processes in a proactive, preventive mode is paramount. Total quality management and continuous quality improvement have a major goal of identifying ways to do the right thing at the right time in the right way by proactive problem-solving.
The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO after midnight
- B. Client should receive a sedative medication prior to the test
- C. Discontinue anti-coagulant therapy prior to the test
- D. No special preparation is necessary
Correct Answer: D
Rationale: This is a non-invasive procedure and does not require preparation other than client education.
The nurse is caring for a client with anorexia nervosa. After experiencing a weight gain of 2 lb (0.9 kg), the client states, 'See what you have done to me? I am fatter and uglier than ever.' Which of the following actions would be most appropriate for the nurse to take?
- A. Acknowledge the client's distress and explore the client's underlying feelings.
- B. Remind the client that gaining weight is a criterion for discharge home.
- C. Encourage the client to write about the client's feelings in a journal
- D. Recommend the client receive cognitive behavioral therapy.
Correct Answer: A
Rationale: Acknowledging distress and exploring feelings builds trust and addresses body image issues. Discharge criteria , journaling , or therapy are less immediate.
The nurse is talking with a client who has Huntington disease and is considering becoming pregnant. Which of the following statements would be appropriate for the nurse to make?
- A. There are alternative methods to expand your family. You should consider adoption.
- B. Genetic counseling is recommended. You will receive a referral before you leave.
- C. Huntington disease inheritance requires both biological parents to carry the gene.
- D. Huntington disease occurs spontaneously and is not likely to affect your children.
Correct Answer: B
Rationale: Huntington's is autosomal dominant, so genetic counseling is essential. Adoption dismisses the client's wishes, both parents carrying the gene is incorrect, and spontaneous occurrence is false.