Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye.
Which of the following actions should the nurse plan to take first?
A. Place a strip of pH paper onto the cul-de-sac of the affected eye.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
B. Administer proparacaine eye drops into the affected eye.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take. Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
C. Install 0.9% sodium chloride solution into the affected eye.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
D. Collect information about the irritant that caused the injury.
The first action the nurse should take is to collect information about the irritant that caused the injury. This information is important because it can help determine the appropriate treatment and irrigation solution to use.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
The first action the nurse should take is to collect information about the irritant that caused the injury.
This information is important because it can help determine the appropriate treatment and irrigation solution to use.
Choice A is incorrect because airborne precautions are used to prevent the spread of infectious diseases that are transmitted through the air, and are not necessary in this situation.
Choice B is incorrect because administering proparacaine eye drops into the affected eye is not the first action the nurse should take.
Proparacaine is a topical anesthetic that can be used to numb the eye before performing ocular irrigation, but it is not the first action the nurse should take.
Choice C is incorrect because installing 0.9% sodium chloride solution into the affected eye is not the first action the nurse should take; the nurse should first collect information about the irritant that caused the injury before performing ocular irrigation.
Similar Questions
A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm.
Which of the following actions should the nurse take?
A. Apply pressure to venipuncture sites for 10 min.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
B. Move the client to a negative pressure room.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
C. Instruct the client to avoid eating raw fruit.
Instruct the client to avoid eating raw fruit. A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection. One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
D. Use contact isolation while providing care.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
Full Explanation
Instruct the client to avoid eating raw fruit.
A low white blood cell count can be caused by cancer or cancer treatment and can increase the risk of infection.
One precaution that can be taken is to avoid all pre-cut fresh fruits and vegetables in delis, restaurants, and grocery stores.
Choice A Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count.
Choice B Moving the client to a negative pressure room is not necessary for a low WBC count.
Choice D Contact isolation while providing care is not necessary for a low WBC count.
A nurse in an emergency department is preparing a client for emergency surgery.
The client's blood alcohol level is 180 mg/dL.
Which of the following actions is the nurse's priority?
A. Insert an indwelling urinary catheter.
Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
B. Insert an NG tube.
Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
C. Obtain consent for surgery.
Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
D. Apply antiembolic stockings.
Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
Full Explanation
The correct answer is choice B: Insert an NG tube.
Choice A rationale: Inserting an indwelling urinary catheter may be necessary for monitoring urine output in some cases, but in this situation, the priority is to insert an NG tube. This will help prevent aspiration during surgery due to the client's high blood alcohol level, which increases the risk of vomiting.
Choice B rationale: Inserting an NG tube is the priority action for the nurse because a high blood alcohol level increases the risk of vomiting and aspiration during surgery. An NG tube can help reduce this risk by keeping the stomach empty and minimizing the chance of aspiration.
Choice C rationale: Obtaining consent for surgery is important, but in emergency situations, consent may be implied, or a designated surrogate decision-maker may provide consent. It is not the priority action for the nurse in this scenario.
Choice D rationale: Applying antiembolic stockings is a preventive measure for deep vein thrombosis, but it is not the priority action in this case. Ensuring the client's safety during surgery, specifically by preventing aspiration, takes precedence due to the client's high blood alcohol level.
A nurse is preparing to administer furosemide to a client who has acute heart failure.
Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?
A. Sodium 136 mEq/L.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B. Creatinine 0.8 mg/dL.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
C. Potassium.2 mEq/L.
Furosemide is a loop diuretic that can cause loss of potassium from the body. A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
D. BUN 18 mg/dL.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
Full Explanation
Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.