Nokea
To remove hard contact lenses from an unresponsive client, the nurse should:
- A. gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. grasp the lens with a gentle pinching motion.
- C. don sterile gloves before attempting the procedure.
- D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.
You may also like to solve these questions
The 24-hour day-night cycle is known as:
- A. circadian rhythm
- B. infradian rhythm
- C. ultradian rhythm
- D. non-REM rhythm
Correct Answer: A
Rationale: The circadian rhythm governs the 24-hour cycle of physiological processes. Infradian rhythms are longer than 24 hours (e.g., menstrual cycle), ultradian rhythms are shorter (e.g., sleep cycles), and non-REM rhythm is not a recognized term.
Which of these types of fluid output is not typically measured?
- A. chest tube drainage
- B. emesis
- C. evaporative water from the respiratory tract
- D. urine
Correct Answer: C
Rationale: Evaporative water from respiration is a form of insensible loss and is typically not measured.
The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
- A. Positioning the client lying down to remove the prosthetic eye
- B. Drying the prosthetic eye with gauze before reinsertion
- C. Cleansing the prosthetic eye with normal saline solution
- D. Telling the client to remove the prosthetic eye weekly for cleaning
Correct Answer: B
Rationale: B: The prosthetic eye should be moist to facilitate insertion; drying it could cause trauma to the socket. A: Lying down aids safe removal. C: Normal saline is appropriate for cleansing. D: Periodic removal every 1-3 weeks is recommended.
Physical examination of a client regarding mobility status should:
- A. begin with gait.
- B. be oriented to time, place, and person.
- C. begin with the Romberg test.
- D. begin with the Tandem Walk test.
Correct Answer: A
Rationale: Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.
A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.