Nokea
What is the primary treatment for a corneal abrasion?
- A. Patch the eye
- B. Topical antibiotics
- C. Surgical repair
- D. Analgesics
Correct Answer: B
Rationale: Topical antibiotics prevent infection while the cornea heals naturally.
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A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct Answer: C
Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows:
1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital.
2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM).
3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases.
4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM).
In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.
Paralytic ileus may occur as a postoperative complication. Which of the following patients would cause you the greatest concern about the development of paralytic ileus?
- A. Kim, a 27-year-old postlaparoscopic appendectomy.
- B. Joyce, a 39-year-old post–open right hemicolectomy.
- C. Nancy, a 56-year-old postmediastinoscopy.
- D. John, a 47-year-old post–total joint replacement.
Correct Answer: B
Rationale: Open abdominal surgeries increase the risk of paralytic ileus.
On assessment of a patient’s learning needs, the nurse determines that a patient taking potassium-wasting diuretics does not know what foods are high in potassium. What is an appropriate nursing diagnosis for this patient?
- A. Risk for cardiac dysrhythmias related to low potassium intake
- B. Deficient knowledge related to not knowing what foods are high in potassium
- C. Imbalanced nutrition: less than body requirements related to lack of intake of potassium-rich foods
- D. Deficient knowledge related to lack of interest regarding dietary requirements when taking diuretics
Correct Answer: B
Rationale: The correct answer is 'Deficient knowledge related to not knowing what foods are high in potassium.' This nursing diagnosis directly addresses the identified learning need. While other options may be indirectly relevant, the primary issue here is the patient's lack of knowledge about potassium-rich foods.
Which physiological response is often associated with surgery-related stress?
- A. Bronchial constriction.
- B. Decreased cortisol levels.
- C. Peripheral vasodilation.
- D. Sodium and water retention.
Correct Answer: D
Rationale: Stress activates the renin-angiotensin-aldosterone system, leading to sodium and water retention.
A patient is receiving a continuous infusion of morphine via an epidural catheter following major abdominal surgery. Which actions should the nurse include in the plan of care (select all that apply)?
- A. Label the catheter as an epidural access
- B. Assess the patient’s pain relief frequently
- C. Use sterile technique when caring for the catheter
- D. Monitor the patient’s level of consciousness (LOC)
Correct Answer: B
Rationale: The correct answers are B. All listed actions are essential for safe and effective care.