Nokea
The nurse should instill the eyedrops into which part of the client's eye?
- A. Onto the cornea
- B. The three carnaus
- C. At the outer canthus
- D. In the lower conjunctival sac
Correct Answer: D
Rationale: Instilling drops in the lower conjunctival sac ensures proper distribution and minimizes corneal irritation.
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The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?
- A. A 22-gauge intravenous line with normal saline infusing.
- B. Wounds covered with moist sterile dressings.
- C. No intravenous pain medication.
- D. Ensure adequate peripheral circulation to both feet.
Correct Answer: D
Rationale: Ensuring peripheral circulation prevents ischemic complications during transfer. A 22-gauge IV is too small for major burns, moist dressings are inappropriate for full-thickness burns, and IV pain medication is needed.
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
- A. A longer period of time is too tiring.
- B. Eschar becomes difficult to remove with longer soaking.
- C. Prolonged soaking causes electrolyte dilution.
- D. The water becomes too cool and may cause chilling.
Correct Answer: C
Rationale: Prolonged soaking in the Hubbard tank can lead to electrolyte dilution, risking imbalances in burn clients who are already prone to fluid and electrolyte shifts.
What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
Which response by the nurse is best at this time?
- A. I'm sure you will look absolutely gorgeous.
- B. I didn't think you were unattractive before.
- C. Your face is swollen with bruises around the eyes.
- D. Your personality is more important than your looks.
Correct Answer: C
Rationale: An honest response about expected swelling prepares the client for recovery.
Which instruction to the nursing assistant is best for maintaining the client's safety and security?
- A. Let the client take your arm while walking.
- B. Take the client's arm while walking.
- C. You'll see the client in front of you and to your side.
- D. Have the client walk independently by your side.
Correct Answer: A
Rationale: Allowing the client to hold the assistant's arm provides stability and safety.