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A nurse in an emergency department is preparing to perform an ocular irrigation
for a client. Which of the following actions should the nurse plan to take?
a. Assess the client's visual acuity prior to irrigation
b. Have the client turn their head toward the unaffected eye
c. Hold the irrigator syringe 3.81 cm (1.5 in) above the eye
d. Perform the irrigation with sterile water for irrigation✔✔✔d. Perform the
irrigation with sterile water for irrigation
A client burned in a house fire has likely suffered a smoke inhalation injury as
well. Consequently, observations of the client's respiratory status are of the highest
priority. A productive cough with sooty sputum indicates smoke inhalation. Clients
with smoke inhalation injury are at high risk for respiratory compromise and
frequently require ventilatory assistance. TEST-TAKING STRATEGY: When
,confronted with a priority-setting data collection question in which all four options
appear plausible, you should always think of you're ABCs: Airway, Breathing,
Circulation. Observations should always follow that order. If a respiratory
observation that is appropriate for the client is listed, it is likely to be the correct
answer.
A provider is planning to remove a client's chest tube. Which instruction should the
nurse give the client to ensure understanding regarding the removal procedure?
Breathe in through pursed lips.
Take a deep breath and hold it.
Exhale and bear down gently.
Take shallow, rapid breaths.✔✔✔✔ANS➖Exhale and bear down gently.
A gentle Valsalva maneuver is recommended to maintain the appropriate amount
of negative pressure in the chest to prevent air entry into the pleural space.
A nurse is caring for a client who is on bed rest and has a new prescription for
enoxaparin (lovenox)subcutaneous. Which of the following actions should the
nurse take?✔✔✔✔ANS➖Inject the medication into the anterolateral abdominal
wall.
,A nurse is caring for a client who is undergoing hemodialysis to treat end-stage
kidney disease ( ESKD). The client reports muscle cramps and a tingling sensation
in their hands. Which of the following medications should the nurse plan to
administer?✔✔✔✔ANS➖Calcium carbonate
A nurse is assessing a client following the administration of magnesium sulfate 1 g
IV bolus. For which of the following adverse effects should the nurse
monitor?✔✔✔✔ANS➖Respiratory paralysis
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the
following laboratory findings should the nurse expect✔✔✔✔ANS➖BUN 32
mg/Dl
A nurse is caring for a client following a below-the knee amputation. The client
states. "my life is over." Which of the following responses should the nurse make?
a. "you are upset. We can talk about this later?"
b. "would you like to meet with another client who is an amputee?"
c. "why do you think your life is over?"
d. "most people can adjust following this surgery"✔✔✔b. "would you like to meet
with another client who is an amputee?"
A nurse in a clinic is providing preventive teaching to an older adult client during a
well visit. The nurse should instruct the client that which of the following
, immunizations are recommended for healthy adults after the age of 60? Select All
That Apply
a. Herpes zoster
b. Influenza
c. Meningococcal
d. Human papillomavirus
e. Pneumococcal polysaccharide✔✔✔a. Herpes zoster
b. Influenza
e. Pneumococcal polysaccharide
A nurse is planning care for a client who has dementia. Which of the following
interventions should the nurse plan to include?
a. Turn off all lights in the client's room at night
b. Place the client's bed at the lowest height
c. Request a prescription for a nightly sedative
d. Assist the client with toileting at least once every 4 hour✔✔✔b. Place the
client's bed at the lowest height
A nurse is assessing a client who has a new diagnosis of type 1 diabetes mellitus.
Which of the following findings indicates that the client is experiencing
hypoglycemia?
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