Nokea
Which of the following actions should the nurse carry out first in a client with a chemical splash in the eye?
- A. Flush the eyes with running water
- B. Instill an antibiotic
- C. Apply an eye pad
- D. Rub the eyes vigorously
Correct Answer: A
Rationale: Immediate flushing with water is essential to dilute and remove the chemical, preventing further damage.
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You are caring for a patient with Sophaged cancer. Which task could be delegated to the nursing assistant?
- A. Assist the patient with oral hygiene.
- B. Observe the patient's response to feedings.
- C. Facilitate expression of grief or anxiety.
- D. Initiate daily weights.
Correct Answer: A
Rationale: Oral hygiene is a basic care task that can be safely performed by a nursing assistant, while the other options require more advanced clinical judgment.
A client develops a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Give morphine IV.
- B. Administer oxygen therapy.
- C. Start an IV infusion of lactated Ringer's.
- D. Initiate cardiac monitoring.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen therapy. Oxygen therapy is the priority intervention for a client with a pulmonary embolism to ensure adequate oxygenation and prevent hypoxia. This helps improve oxygen levels in the blood and supports vital organ function. Morphine IV (choice A) may be given for pain relief but is not the initial priority. Starting an IV infusion of lactated Ringer's (choice C) and initiating cardiac monitoring (choice D) may be necessary but do not address the immediate need for oxygenation in a pulmonary embolism.
What term best describes an item that is a microorganism or prion that is generally harmless to humans?
- A. Nonpathogenic
- B. Pathogenic
- C. Infection
- D. Helminth
Correct Answer: A
Rationale: The correct answer is A because nonpathogenic microorganisms do not typically cause harm to humans.
An 80-year-old patient is placed in isolation when infected with methicillin-resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to
- A. a fluid and electrolyte imbalance.
- B. a stimulating environment.
- C. sensory deprivation.
- D. sundowning.
Correct Answer: C
Rationale: Isolation can lead to sensory deprivation, affecting cognitive function.
Which vitamin does a client lack if there is a problem with the absorption of calcium?
- A. Vitamin A
- B. Vitamin B
- C. Vitamin C
- D. Vitamin D
Correct Answer: D
Rationale: Vitamin D is essential for calcium absorption in the intestines. A deficiency impairs this process.