Nokea
The nurse is preparing to irrigate the student's eye. What steps are appropriate in completing the irrigation? Select all that apply.
- A. The use the solution directly into the center of the eye.
- B. Tilt the head toward the opposite eye.
- C. Perform hand hygiene and put on gloves.
- D. Offer the client a paper tissue.
- E. Place the solution into the conjunctival sac.
- F. Continue eye irrigations until all redness is resolved.
Correct Answer: C,E
Rationale: Hand hygiene and gloves prevent infection, and placing the solution in the conjunctival sac ensures effective irrigation without damaging the cornea.
You may also like to solve these questions
While the nurse is assessing the client hospitalized with recurrent lower-extremity cellulitis, the client states, 'I have athlete's foot; do you want to check it?' The nurse concludes that this information is significant for what reason?
- A. Cellulitis is commonly caused by a similar fungal infection.
- B. Both infections should resolve with topical fungicide therapy.
- C. Painful neuralgia can occur after the cellulitis infection has resolved.
- D. The skin disruption with tinea pedis may be the cause of the cellulitis.
Correct Answer: D
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Chronic athlete's foot causes minute breaks in the skin, allowing bacteria on the skin to enter the tissue and cause the infectious process. Cellulitis is caused by a bacterial infection, not fungal. Cellulitis requires antibiotics, not fungicides. Neuralgia is associated with herpes zoster, not cellulitis.
The nurse is speaking with clients during a wellness fair. What information should the nurse provide to prevent or minimize burn injury? Select all that apply.
- A. Wear flame-retardant clothing, especially near flames.
- B. Use 'stop, drop, and roll' maneuvers if clothing is on fire.
- C. Burn candles that are placed only in glass containers.
- D. Put out a cooking fire by throwing salt on the fire.
- E. Install smoke detectors, including one by the furnace.
Correct Answer: A,B,E
Rationale: The nurse should discuss flame-retardant clothing. 'Stop, drop, and roll' maneuvers should be used to minimize burn. Smoke detectors should be included throughout the home, including one near the furnace. It does not matter what type of container holds the burning candle. For a small fire on the stove, covering the flame with a lid is recommended.
If a client with a middle ear infection reports the following symptoms, which one suggests that the infection has spread to the inner ear?
- A. Temporal headaches
- B. A sore throat
- C. Nasal congestion
- D. Postural dizziness
Correct Answer: D
Rationale: Postural dizziness suggests inner ear involvement, such as labyrinthitis.
The nurse is caring for clients in an outpatient surgery clinic. Which client should be assessed first?
- A. The client scheduled for a skin biopsy who is crying.
- B. The client who had surgery three (3) hours ago and is sleeping.
- C. The client who needs to void prior to discharge.
- D. The client who has received discharge instructions and is ready to go home.
Correct Answer: A
Rationale: Crying suggests emotional distress or pain, requiring immediate assessment. Sleeping, voiding, and discharge-ready clients are stable.
The nurse is caring for the client with a large, open sternal wound resulting from a burn injury. The client is receiving enteral feeding, Oxepa (an anti-inflammatory, pulmonary 1.5 Cal/mL formula), at 25 mL/hour. Which laboratory value finding best indicates that the client is receiving inadequate nutrition?
- A. Phosphorus
- B. Platelets
- C. Prealbumin
- D. Potassium
Correct Answer: C
Rationale: Prealbumin is used to evaluate nutritional status. A low level of prealbumin indicates inadequate nutrition. Prealbumin has a half-life of 2 days and reflects changes in serum protein stores more rapidly than other indices. The phosphorus level decreases in malnutrition as well as other conditions, but this is not the best indicator of inadequate nutrition. Platelets are essential to blood clotting and may or may not be altered with inadequate nutrition. Potassium is the major cation within the cell and may be low due to renal failure or GI disorders.