An environmental service attendant is brought to an urgent care clinic after having bleach splash to their eyes and face.
The client spent 10 minutes at the eye wash station rinsing their face and eyes prior to arrival.
The client reports 9 (0-10 scale) of burning to their eyes and periorbital area.
The sclera of both eyes are deep red.
The urgent care nurse will first:

Review the safety data sheet online for products with bleach.

Continue irrigating eyes with saline until pain-free, then check pH of both eyes.

Contact the physician for miotic ophthalmic drops for pain control.

Assess visual acuity of both eyes and check vital signs.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Reviewing the safety data sheet does not directly alleviate the immediate chemical injury or prevent further damage. Immediate irrigation of the eyes is the priority after chemical exposure to minimize damage to the ocular surface.

Choice B rationale

Continuous irrigation removes chemical agents from the eyes and prevents further damage. Ensuring a pain-free state and checking pH confirm the removal of irritants, essential for preventing deeper eye tissue damage.

Choice C rationale

Miotic drops reduce intraocular pressure but do not address acute chemical injury. Pain relief is secondary to irrigating and neutralizing pH, which directly prevents ongoing tissue damage and irritation.

Choice D rationale

Assessing visual acuity and vital signs is important but secondary to preventing further chemical penetration. Immediate irrigation prevents damage progression and is prioritized over assessments during the acute phase of exposure.

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Correct Answer is C

Explanation

Choice A rationale

Soft restraints are utilized for agitation but are not prioritized in epilepsy care. Emergency equipment like suction ensures airway safety during seizures.

Choice B rationale

Glasgow Coma Scale evaluates neurological function but is less relevant for epilepsy management compared to essential tools like suction equipment for airway protection.

Choice C rationale

Suction equipment and oxygen are vital in epilepsy management to clear secretions and maintain oxygenation during seizures. Patent IV access allows rapid administration of emergency medications.

Choice D rationale

Dextrose infusion is used to treat hypoglycemia rather than seizures. Epilepsy care prioritizes tools like suction and oxygen for immediate seizure-related complications. .

A. Decreased level of consciousness. B. Elevated blood pressure and patient reports headache. C. Patient has vomited once and reports persistent nausea. D. Positive Babinski's sign. E. Fever and cardiac dysrhythmias.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination.Which of the following options are priority to institute?

Correct Answer is C

Explanation

The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-P

Correct Answer is ["A","B","C"]

Explanation

The patient diagnosed with acquired immunodeficiency syndrome (AIDS) states that they have developed purple, brown spots on their body.Which opportunistic infection does the nurse suspect?

The nurse is developing a teaching plan for the client with glaucoma.Which of the following instructions would the nurse include in the plan of care?

Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

The nurse is caring for a patient with a spinal cord injury at the level of C-7. The patient is having a severe headache, hypertension, bradycardia, diaphoresis, and flushing of the face with pale, cold skin below the level of the injury.What are the priority nursing interventions?

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