The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Instill anesthetic eye drops in both eyes

Perform a visual acuity exam

Determine the pH of the chemical splash

Irrigate both eyes with normal saline

Answer and Explanation

The Correct Answer is D

A. Anesthetic eye drops can help with pain, but irrigation is the priority to prevent further damage.

B. A visual acuity exam is part of the assessment but should be performed after initial irrigation to prevent further damage.

C. Determining the pH of the chemical splash can guide further treatment but is secondary to immediate irrigation to dilute and remove the chemical.

D. Irrigating both eyes with normal saline is the priority action to dilute and flush out the chemical, reducing the risk of further injury.

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Correct Answer is A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

A. Padded tongue blades to prevent injury in the event of seizure B. Soft wrist restraints to prevent injury C. Ambu bag and oxygen connection for respiratory distress D. Wrenches for emergency removal of traction equipment E. Oral suction tube (Yankaur) for secretion removal

Correct Answer is ["C","D","E"]

Explanation

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

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The emergency department nurse is caring for a patient who has had a chemical splash in both eyes. What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

Correct Answer is A

Explanation

The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

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