Nokea
The nurse is caring for a client who sustained injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass was lodged in the client's eye. The initial nursing intervention should be which of the following?
- A. Attempt to carefully remove the glass from the eye
- B. Reassure the client that everything is okay
- C. Administer a sedative for pain relief
- D. Advise the client to remain in a sitting position until a specialist arrives
Correct Answer: D
Rationale: A foreign object like glass in the eye requires specialist intervention. Keeping the client in a sitting position minimizes further damage until a specialist evaluates. Attempting removal, false reassurance, or sedation without specialist input is inappropriate.
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A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply.
- A. Epinephrine
- B. Acetaminophen
- C. Diphenhydramine
- D. Hydrocortisone
- E. Pantoprazole
Correct Answer: A,C,D
Rationale: Epinephrine treats severe allergic reactions (anaphylaxis), diphenhydramine manages mild to moderate allergic symptoms, and hydrocortisone reduces inflammation in allergic reactions. Acetaminophen is for fever or pain, and pantoprazole is for gastric issues, not allergic reactions.
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:
- A. Use benchmarking procedures to compare the findings with other nursing units in the hospital.
- B. Ask the staff education department to conduct an educational session about preventing pressure ulcers.
- C. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.
- D. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
Correct Answer: C
Rationale: A quality improvement plan addresses root causes, proposes solutions, and sets measurable outcomes, effectively reducing pressure ulcer incidence.
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) promotes therapeutic communication and understanding. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic.