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Question 1 of 5

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time?

Correct Answer: C

Rationale: Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye- containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye

Question 2 of 5

The most common cause of injury from a house fire is:

Correct Answer: D

Rationale: Inhalation injury, from smoke and toxic gases, is the most common cause of house fire injuries, often leading to respiratory compromise. Thermal damage is also significant but less frequent. Accident Prevention

Question 3 of 5

A spouse brings a client with a history of previous suicide attempts to the emergency department due to erratic behavior and expressions of hopelessness. When the triage nurse asks if the client is having suicidal thoughts, the client shrugs their shoulders. What action should the triage nurse take?

Correct Answer: C

Rationale: Given the history of suicide attempts and current hopelessness, a noncommittal response like shrugging suggests a high suicide risk. One-to-one observation ensures safety. Documenting no suicidality is inaccurate, frequent observation is insufficient, and returning to the waiting room is unsafe.

Question 4 of 5

The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

Correct Answer: C

Rationale: Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for the amount of drainage.

Question 5 of 5

Which of the following observations indicates the possibility of a birth injury related to forceps delivery?

Correct Answer: A

Rationale: Asymmetry of the mouth may indicate facial nerve injury, a potential complication of forceps delivery due to pressure on the facial nerve.

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