Nokea
The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
- A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
- B. The child should be allowed to instill his own eyedrops.
- C. Allow the mother to instill the eyedrops.
- D. If the eye is clear from any redness or edema, the eyedrops should be held.
Correct Answer: A
Rationale: Cleansing the eye removes exudate, ensuring effective administration of eyedrops for conjunctivitis.
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Nurses must be familiar with the American Nurses Association (ANA) Code of Ethics for Nurses. The nurse understands that which ethical principle is defined as the nurse's duty to do no harm? Fill in the blank.
- A. Nonmaleficence
- B. Bneficence
- C. autonomy
Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm, a core duty in nursing practice.
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: facilitates swallowing and movement of tube through GI tract
The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.
A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for:
- A. Changes in vision
- B. Difficulty in speaking
- C. Impaired judgment
- D. Hearing impairment
Correct Answer: A
Rationale: The occipital lobe processes visual information, so injury to this area is likely to cause visual disturbances, such as blurred vision or visual field deficits.