ADH Exam 2 Lippincott

Thirty people are injured in a train derailment. Which client should be transported to the hospital fi rst? ■ 1. A 20-year-old who is unresponsive and has a high injury to his spinal cord. ■ 2. An 80-year-old who has a compound fracture of the arm. ■ 3. A 10-year-old with a laceration on his leg. ■ 4. A 25-year-old with a sucking chest wound.

4. During a disaster, the nurse must make diffi cult decisions about which persons to treat fi rst. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classifi ed as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the fi rst to be transported to the health care facility.

To approach a deaf client, the nurse should do which of the following fi rst? ■ 1. Knock on the room's door loudly. ■ 2. Close and open the vertical blinds rapidly. ■ 3. Talk while walking into the room. ■ 4. Get the client's attention.

4. The nurse should avoid startling the client who is deaf and should obtain the attention of the client before speaking. The client who is deaf cannot hear knocking on the door or talking. Opening the blinds is not a helpful way to get the client's attention

A short time after cataract surgery, the client complains of nausea. The nurse should fi rst: ■ 1. Instruct the client to take a few deep breaths until the nausea subsides. ■ 2. Explain that this is a common feeling that will pass quickly. ■ 3. Tell the client to call the nurse promptly if vomiting occurs. ■ 4. Medicate the client with an antiemetic, as ordered.

4. A prescribed antiemetic should be administered as soon as the client complains of nausea following a cataract extraction. Vomiting can increase intraocular pressure, which should be avoided after eye surgery because it can cause complications. Deep breathing is unlikely to relieve nausea. Postoperative nausea may be common; however, it doesn't necessarily pass quickly and can lead to vomiting. Telling the client to call only if vomiting occurs ignores the client's need for comfort and intervention to prevent complications.

Although all of the following measures might be useful in reducing the visual disability of a client with adult macular degeneration (AMD), which measure should the nurse teach the client primarily as a safety precaution? ■ 1. Wear a patch over one eye. ■ 2. Place personal items on the sighted side. ■ 3. Lie in bed with the unaffected side toward the door. ■ 4. Turn the head from side to side when walking.

4. To expand the visual fi eld, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. A patch does not address the problem of hemianopsia. Appropriate client positioning and placement of personal items will increase the client's ability to cope with the problem but will not affect safety.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. ■ 1. Triage priority. ■ 2. Identifying information when possible (such as name, age, and address). ■ 3. Medications and treatments administered. ■ 4. Presence of jewelry. ■ 5. Next of kin.

1, 2, 3. Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.

Several clients have come to the emergency department after a possible bioterrorist act of arsenic overexposure. The nurse should assess these clients for which signs or symptoms immediately following the poisoning? Select all that apply. ■ 1. Violent vomiting. ■ 2. Severe diarrhea. ■ 3. Abdominal pain. ■ 4. Sensory neuropathy. ■ 5. Persistent cough.

1,2,3 8. 1, 2, 3. When arsenic overexposure occurs, the symptoms include violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. Dehydration can lead to shock and death. After the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur. A persistent cough is not a sign of arsenic exposure.

To prepare the irrigation solution used for removal of cerumen, the nurse should use: ■ 1. Normal saline. ■ 2. Sterile water. ■ 3. Antiseptic solution. ■ 4. Warm tap water.

1. Normal saline is the solution that is generally used to irrigate the ear. Sterile water will cause tissue damage. An antiseptic solution is not typically used unless an infection is present. Warm tap water may cause tissue damage.

A client with detachment of the retina is to patch both eyes. The expected outcome of patching is to: ■ 1. Reduce rapid eye movements. ■ 2. Decrease the irritation caused by light entering the damaged eye. ■ 3. Protect the injured eye from infection. ■ 4. Rest the eyes to promote healing.

1. Patching the eyes helps decrease random eye movements that could enlarge and worsen retinal detachment. Although clients with eye injuries frequently are light-sensitive, and preventing infection is important, the specifi c goal is to reduce rapid eye movements. Resting the eye is an indirect way of stating the objective.

The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? ■ 1. Remain in a semi-Fowler's position. ■ 2. Position the feet higher than the body. ■ 3. Lie on the operative side. ■ 4. Place the head in a dependent position.

1. The nurse should instruct the client to remain in a semi-Fowler's position or on the nonoperative side. Positioning the feet higher than the body does not affect the operative eye; placing the head in a dependent position could increase pressure within the eyes

Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply. ■ 1. Call in extra staff to assist with the possibility of more clients with the same condition. ■ 2. Isolate all the suspected clients in the emergency department in one area. ■ 3. Call housekeeping for diluted household bleach. ■ 4. Restrict visitors from the emergency department. ■ 5. Quarantine all contacts.

2, 3, 4. The nurse should isolate all the suspected clients in the emergency department in one area and restrict visitors from the emergency department to minimize exposure to others. The nurse should also obtain diluted household bleach (1:100) to decontaminate areas suspected of coming in contact with the virus. There is no indication at this time that extra staff is needed, so the nurse should not call in extra staff, to minimize exposure to health care workers. It is not necessary to quarantine contacts until a diagnosis is confi rmed. In addition, it is the role of the public health offi cer to issue the quarantine if needed.

The nurse has been assigned to a client who is hearing impaired and reads speech. Which of the following strategies should the nurse incorporate when communicating with the client? Select all that apply. ■ 1. Avoiding being silhouetted against strong light. ■ 2. Not blocking out the person's view of the speaker's mouth. ■ 3. Facing the client when talking. ■ 4. Having bright light behind so the individual can see. ■ 5. Ensuring the client is familiar with the subject material before discussing. ■ 6. Talking to the client while doing other nursing procedures.

1, 2, 3, 5. When working with a client who is hearing impaired and speech reads, the presenter must face the person directly and devote full attention to the communication process. In addition, it will be useful for the client that the speaker not be too silhouetted against strong light, that the speaker's mouth not be blocked from the client's view, and that there are no objects in the mouth of the speaker. Finally, it is recommended that the presenter provide the client with the needed information to study before reviewing. This will provide the client with the ability to use contextual clues in speech reading.

There has been a fi re in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. ■ 1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA). ■ 2. A 20-year-old who inhaled the smoke of the fi re. ■ 3. A 50-year-old diabetic with fi rst- and seconddegree burns on his left forearm (about 5% of his BSA). ■ 4. A 30-year-old with second-degree burns on the back of his left leg. ■ 5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA)

1, 2, 3. Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their body surface area (BSA), clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease

The nurse should assess the client with Ménière's disease for the intended outcomes of which of the following medications that are commonly used to manage the disease? Select all that apply. ■ 1. Antihistamines. ■ 2. Antiemetics. ■ 3. Diuretics. ■ 4. Non-steroidal anti-infl ammatory drugs (NSAIDs). ■ 5. Antipyretics

1, 2, 3. Since the symptoms of Ménière's disease are associated with a change in the fl uid volume of the inner ear, a wide variety of medications may be used in an attempt to control the signs/symptoms of Ménière's disease, including antihistamines, antiemetics, tranquilizers, and diuretics. NSAIDs and antipyretics play no signifi - cant role in Ménière's disease management.

An explosion at a chemical plant produces fl ames and smoke. More than 20 persons have burn injuries. Which victims should be transported to a burn center? Select all that apply. ■ 1. The victim with chemical spills on both arms. ■ 2. The victim with third-degree burns of both legs. ■ 3. The victim with fi rst-degree burns of both hands. ■ 4. The victim in respiratory distress. ■ 5. The victim who inhaled smoke.

1, 2, 4, 5. Victims with chemical burns, second- and third-degree burns over more than 20% of their body surface area, and those with inhalation injuries should be transported to a burn center. The victim with fi rst-degree burns of his hands can be treated with fi rst-aid on the scene and referred to a health care facility.

There has been an increase in medication errors and errors in ordering laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply. ■ 1. When a medication order or critical lab result is received verbally or over the telephone. ■ 2. When any verbal or phone order is received. ■ 3. Whenever a written order or printed critical test result is received. ■ 4. When the unit secretary takes a phone order. ■ 5. When the agency uses computerized health care records.

1, 2. A National Patient Safety Goal of The Joint Commission is to improve the effectiveness of communication among caregivers. For verbal or telephone orders, or for telephone reporting of critical test results, one must verify the complete order or test result by having the individual receiving the information record "read- back" the complete order or test result. The Unit Secretary is not a licensed health care professional who has a Scope of Practice or the authority to receive orders or results. The type of charting system used by the health care agency is not a factor in using "read back" orders.

The nurse notices a pair of nervous-acting individuals entering the emergency department. When reporting suspicious activity, the nurse should include which of the following in the report? Select all that apply. ■ 1. Vehicle/s description. ■ 2. Current location of parties involved. ■ 3. Names and phone numbers of parties involved. ■ 4. Relationship to hospitalized client. ■ 5. Tone of voice of each party involved.

1, 2. All suspicious individuals or activities should be reported as soon as possible to the security department. When reporting an incident, nurses/employees should provide the following: (a) type of incident; (b) persons involved/physical description; (c) vehicles involved and description; (d) date and time the incident occurred; (e) location where the incident occurred; (f) weapons involved and (g) current location of parties involved. All reports of threats, actual episodes of violence, or suspicious individuals or activities must be investigated.

A suspected outbreak of anthrax has been transmitted by skin exposure. A client is admitted to the emergency department with lesions on the hands. The physician prescribes antibiotics and sends the client home. What should the nurse instruct the client to do? Select all that apply. ■ 1. Take the prescribed antibiotics for 60 days. ■ 2. Avoid contact with other members of the family during the treatment period. ■ 3. Wear a mask for 60 days. ■ 4. Expect the skin lesions to clear up within 1 to 2 weeks. ■ 5. Wash hands frequently.

1, 4. Anthrax is treated with antibiotics and the client must continue the prescription for 60 days, even if symptoms do not persist. The client may have skin lesions at the point of contact, with macula or papule formation; the eschar will fall off in 1 to 2 weeks. Clients with anthrax are not contagious; the client does not need to follow isolation procedures at home. Anthrax from skin exposure is not transmitted by respiratory contact and the client does not need to wear a mask

During the emergent (resuscitative) phase of burn injury, which of the following indicates that the client is requiring additional volume with fl uid resuscitation? ■ 1. Serum creatinine level of 2.5 mg/dL. ■ 2. Little fl uctuation in daily weight. ■ 3. Hourly urine output of 60 mL. ■ 4. Serum albumin level of 3.8.

1. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fl uid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/hour. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fl uid status. Little fl uctuation in weight suggests that there is no fl uid retention and the intake is equal to output. Exudative loss of albumin occurs in burns causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 gm/dL.

The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse scans the client's identifi cation band and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next? ■ 1. Contact the pharmacist immediately to check the order and the barcode label for accuracy. ■ 2. Administer the medication now, knowing the medication is labeled and the client is identifi ed. ■ 3. Report the problem to the information technology team to have the barcode system recalibrated. ■ 4. Ask another nurse to verify the medication and the client so the medication can be given now.

1. The nurse should contact the pharmacist fi rst to be sure the medication is labeled for administration to this client. The nurse should not administer the drug until all safety precautions have been observed; the nurse should also not ask another nurse to verify the medication or client. Later, if the problem cannot be resolved with re-labeling the medication, the nurse or pharmacist can contact the information technology team to check the barcode system.

There is a shooting in a shopping mall. Three victims with gunshot wounds are brought to the emergency department. What should the nurse do to preserve forensic evidence? Select all that apply. ■ 1. Cut around blood stains to remove clothing. ■ 2. Place each item of clothing in a separate paper bag. ■ 3. Hang wet clothing to dry. ■ 4. Refrain from documenting client statements. ■ 5. Place bullets in a sterile container.

2, 3. Preserving forensic evidence is essential for investigative purposes following injuries that may be caused by criminal intent. The nurse should put each item of clothing in a separate paper bag and label it; wet clothing should be hung to dry. The nurse should not cut or otherwise unnecessarily handle clothing, particularly clothing with such evidence as blood or body fl uids. The nurse should document carefully the client's description of the incident and use quotes around the client's exact words where possible. The documentation will become a part of the client's record and can be subpoenaed for subsequent investigation. The nurse should not handle bullets from the client because they are an important piece of forensic evidence.

A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply. ■ 1. Remove all tubes and I.V. lines. ■ 2. Cover the body with a sheet. ■ 3. Notify the family. ■ 4. Transport the body to the morgue. ■ 5. Notify the chaplain.

2, 4. The UAP can cover the body and transport it to the morgue. Deaths by gunshot wound are considered reportable deaths. All evidence in a reportable death, including tubes and I.V. lines, should remain intact until the coroner has been contacted. The health care provider should be the one to notify the family. The nurse should be the one to notify the chaplain.

A client is receiving fl uid replacement with Lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 36.2° C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: ■ 1. Furosemide (Lasix). ■ 2. Fresh frozen plasma. ■ 3. I.V. rate increase. ■ 4. Dextrose 5%.

3. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fl uid volume replacement. Furosemide is a diuretic that should not be given due to the existing fl uid volume defi cit. Fresh frozen plasma is not indicated. It is given for clients with defi cient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, Normal Saline, or albumin.

After the initial phase of the burn injury, the client's plan of care will focus primarily on: ■ 1. Helping the client maintain a positive selfconcept. ■ 2. Promoting hygiene. ■ 3. Preventing infection. ■ 4. Educating the client regarding care of the skin grafts

3. The infl ammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There is a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection

The nurse in the immediate care clinic is assessing an 80-year-old client who lives with his son's family and has scald burns on his hands and both forearms (fi rst- and second-degree burns on 10% of his body surface area). What should the nurse do fi rst? ■ 1. Clean the wounds with warm water. ■ 2. Apply antibiotic cream. ■ 3. Refer the client to a burn center. ■ 4. Cover the burns with a sterile dressing.

3. The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next? ■ 1. Hold an interdisciplinary meeting on the client's behalf promptly. ■ 2. Consult with psychiatry. ■ 3. Listen to the client and observe the body language. ■ 4. Address the client by fi rst name upon entering the room.

31. 3. By listening to the client should they speak and by noting body language, the nurse may be better able to ascertain the client's physical and cognitive status. The nurse should not utilize the first name of a client unless a client provides permission to do so. To consult with psychiatry would not be appropriate unless ordered by the primary care physician. An interdisciplinary meeting would not enable the nurse to understand why the client is staring straight ahead. Perhaps the client is only deep in thought.

An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant "ringing" in both ears. How should the nurse respond to the client's comment? ■ 1. Tell the client that "ringing" in the ears is associated with the aging process. ■ 2. Refer the client to have a Weber test. ■ 3. Schedule the client for audiometric testing. ■ 4. Explain to the client that the "ringing" may be related to the aspirin.

4. Tinnitus (ringing in the ears) is an adverse effect of aspirin. Aspirin contains salicylate, which is an ototoxic drug that can induce reversible hearing loss and tinnitus. The nurse should encourage the client to inform the physician of the symptom. Tinnitus is not a function of aging. The Weber test and audiometric testing are useful for determining hearing loss but are not necessarily helpful in the management or diagnosis of drug-induced tinnitus.

A client is having a cataract removed and will use eyeglasses after the surgery. The nurse should develop a teaching plan that includes which of the following? Select all that apply. ■ 1. Images will appear to be one-third larger. ■ 2. Look through the center of the glasses. ■ 3. The changes will be immediate. ■ 4. Use handrails when climbing stairs. ■ 5. Stay out of the sun for 2 weeks.

■ 1. Images will appear to be one-third larger. ■ 2. Look through the center of the glasses. ■ 4. Use handrails when climbing stairs. 1, 2, 4. The use of glasses following cataract surgery does not totally restore binocular vision. Glasses will cause images to appear larger and peripheral vision will be distorted; the client should look through the center of the glasses and turn his or her head to view objects in the periphery. The client should also use caution when walking or climbing stairs until he or she has adjusted to the change in vision. Changes in vision following cataract surgery are not immediate and the nurse can instruct the client to be patient while adjusting to the changes. The client does not need to stay out of the sun, but should wear dark glasses to prevent discomfort from photophobia.

The client has had a cataract removed. The nurse's discharge instructions should include which of the following? ■ 1. Keep the head aligned straight. ■ 2. Utilize bright lights in the home. ■ 3. Use an eye shield at night. ■ 4. Change the eye patch as needed.

■ 3. Use an eye shield at night. 3. 3. Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual fi eld to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.

A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? ■ 1. Enteric precautions. ■ 2. Hand-washing precautions. ■ 3. Reverse isolation. ■ 4. Standard precautions.

■ 4. Standard precautions.4. Transmission of SARS can be contained by following standard (universal) precautions, which include masks, gowns, eye protection, hand washing, and safe disposal of needles and sharps. The disease is spread by the respiratory, not enteric, route. Hand washing alone is not sufficient to prevent transmission. Reverse isolation (protection of the client) is not suffi cient to prevent transmission.

Which of the following should the nurse provide as part of the information to prepare the client for tonometry? ■ 1. Oral pain medication will be given before the procedure. ■ 2. It is a painless procedure with no adverse effects. ■ 3. Blurred or double vision may occur after the procedure. ■ 4. Medication will be given to dilate the pupils before the procedure.

■ 2. It is a painless procedure with no adverse effects. 2. Tonometry, which measures intraocular pressure, is a simple, noninvasive, and painless procedure that requires no particular preparation or postprocedure care and carries no adverse effects. It is not necessary to dilate the pupils for tonometry.

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should fi rst-aid for this victim include? Select all that apply. ■ 1. Establish an airway with the jaw-thrust maneuver. ■ 2. Immobilize the spine. ■ 3. Logroll the victim to a side-lying position. ■ 4. Elevate the feet 6″ (15.2 cm). ■ 5. Place a cervical collar around the neck.

1, 2. The victim of a neck injury should be immobilized and moved as little as possible. It is also important to ensure an open airway; this can be accomplished with the jaw-thrust maneuver, which does not require tilting the head. The victim should not be rolled to a side-lying position nor have his feet elevated. Both actions can cause additional injury to the spinal cord. Placing a cervical collar causes movement of the spinal column and should not be done as a fi rst-aid measure

The best method to remove cerumen from a client's ear involves: ■ 1. Inserting a cotton-tipped applicator into the external canal. ■ 2. Irrigating the ear gently. ■ 3. Using aural suction. ■ 4. Using a cerumen curette.

2. Irrigation is the fi rst strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The fl ow of the water must be behind the impaction to remove the cerumen from the canal. A cotton-tipped applicator or other device is not appropriate because it can cause damage to the eardrum. Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.

The nurse should plan to begin rehabilitation efforts for the burn client: ■ 1. Immediately after the burn has occurred. ■ 2. After the client's circulatory status has been stabilized. ■ 3. After grafting of the burn wounds has occurred. ■ 4. After the client's pain has been eliminated

2. Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.

Which of the following statements indicates the client understands the expected course of Ménière's disease? ■ 1. "The disease process will gradually extend to the eyes." ■ 2. "Control of the episodes is usually possible, but a cure is not yet available." ■ 3. "Continued medication therapy will cure the disease." ■ 4. "Bilateral deafness is an inevitable outcome of the disease."

2. There is no cure for Ménière's disease, but the wide range of medical and surgical treatments allows for adequate control in many clients. The disease often worsens, but it does not spread to the eyes. The hearing loss is usually unilateral.

The nurse is conducting a focused assess of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for: ■ 1. Paralytic ileus. ■ 2. Gastric distention. ■ 3. Hiatal hernia. ■ 4. Curling's ulcer.

4. Curling's ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn injury. The incidence of ulceration appears proportional to the extent of the burns and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and stress. Hiatal hernia is not necessarily a potential complication of a burn injury.

Which of the following is a potential complication following cataract surgery? Select all that apply. ■ 1. Acute bacterial endophthalmitis. ■ 2. Retrobulbar hemorrhage. ■ 3. Rupture of the posterior capsule. ■ 4. Suprachoroidal hemorrhage. ■ 5. Vision loss.

■ 1. Acute bacterial endophthalmitis ■ 5. Vision loss. 1, 5. Acute bacterial endophthalmitis can occur in about 1 out of 1,000 cases. Organisms that are typically involved include Staphylococcus epidermidis, S. aureus, and Pseudomonas and Proteus species. Vision loss is one result of acute bacterial infection. In addition, vision loss can be the result of malposition of the intraocular lens implant or opacifi cation of the posterior capsule. Retrobulbar hemorrhage is a complication that may occur right before surgery and is a result of retrobulbar infi ltration of anesthetic agents. Rupture of the posterior capsule and suprachoroidal hemorrhage are both complications that can result during surgery.

Several clients who work in the same building are brought to the emergency department. They all complain of similar clinical manifestations, including fever, headache, a rash over the entire body, and abdominal pain with vomiting and diarrhea. Upon initial assessment, the nurse fi nds that each client has low blood pressure and has developed petechiae in the area where the blood pressure cuff was infl ated. Which isolation precautions should the nurse initiate? ■ 1. Contact isolation with double-gloving and shoe covers. ■ 2. Respiratory isolation with positive pressure rooms. ■ 3. Enteric precautions. ■ 4. Reverse isolation.

■ 1. Contact isolation with double-gloving and shoe covers. 1. The nurse should institute treatment for hemorrhagic fever viruses, including contact isolation with double-gloving and shoe covers, strict hand hygiene, and protective eyewear. The nurse should start respiratory isolation with negative pressure rooms, not positive pressure rooms. Enteric precautions are not needed because the virus is spread by droplet and contact. Reverse isolation protects the client; in this situation, the health care team also needs protection

The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into the client's eye prior to cataract surgery. Which of the following is the expected outcome? ■ 1. Dilation of the pupil and blood vessels. ■ 2. Dilation of the pupil and constriction of blood vessels. ■ 3. Constriction of the pupil and constriction of blood vessels. ■ 4. Constriction of the pupil and dilation of blood vessels.

■ 2. Dilation of the pupil and constriction of blood vessels.

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? ■ 1. "Place your head between your knees." ■ 2. "Concentrate on rhythmic deep breathing." ■ 3. "Close your eyes tightly." ■ 4. "Assume a reclining or fl at position."

■ 4. "Assume a reclining or fl at position."

21. The expected outcome of using miotics to treat glaucoma is: ■ 1. Paralyzing ciliary muscles. ■ 2. Constricting intraocular vessels. ■ 3. Constricting the pupil. ■ 4. Relaxing ciliary muscles.

■ 3. Constricting the pupil 3. A miotic agent constricts the pupil and contracts ciliary musculature. These effects widen the fi ltration angle and permit increased outfl ow of aqueous humor. Miotics also cause vasodilation of the intraocular vessels, where intraocular fl uids leave the eye, also increasing aqueous humor outfl ow. Mydriatics cause cycloplegia, or paralysis of the ciliary muscle.