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.
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The nurse is taking the client's temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?
- A. Ensure that the probe tip seals the ear canal prior to taking a temperature.
- B. Irrigate the ear canal with sterile saline before obtaining the temperature.
- C. When inserting the thermometer in the adult ear, pull downward on the pinna.
- D. Check to be sure that the client does not have any tympanostomy tubes in place.
Correct Answer: A
Rationale: A: Sealing the ear canal ensures accurate readings. B: Irrigation is unnecessary and affects results. C: The pinna is pulled upward in adults. D: Tympanostomy tubes don't affect readings after initial placement.
Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct Answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.