A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first?

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Question 1 of 5

A 54-year-old patient arrives in the emergency department (ED) after exposure to powdered lime at work. Which action should the nurse take first?

Correct Answer: D

Rationale: The correct answer is D because brushing off any visible powder on the skin and clothing is the first step in managing exposure to powdered lime. This action helps to remove the source of exposure and prevent further absorption through the skin. It is crucial to prevent additional contact and reduce the risk of further harm. Obtaining vital signs (choice A) and a complete blood count (choice B) can be important but should come after the initial decontamination. Decontaminating the patient by showering with water (choice C) is not recommended for lime exposure as it can react with water and cause further injury.

Question 2 of 5

Which patient should the nurse refer for hospice care?

Correct Answer: C

Rationale: The correct answer is C because the patient with AIDS-related dementia requires palliative care and pain management, which are key components of hospice care. This patient is likely in the terminal stage of their illness and would benefit from the comprehensive support provided by hospice services. Choice A is incorrect because the patient's children's inability to discuss dying issues does not necessarily indicate a need for hospice care. Choice B is incorrect as chronic severe pain due to spinal arthritis is not a sole criterion for hospice referral. Choice D is incorrect as advanced liver failure alone does not automatically qualify a patient for hospice care.

Question 3 of 5

The nurse is educating a group of nursing students about end-of-life care. Which statement by a student indicates the need for further teaching?

Correct Answer: C

Rationale: The correct answer is C because maintaining hydration and nutrition until the patient dies is not always appropriate in end-of-life care, as some patients may be unable to tolerate oral intake or may be close to the end of life where artificial nutrition and hydration may not provide benefit and may even cause discomfort. Explanation: A: A is correct because terminally ill patients may indeed benefit from continuous pain management to ensure comfort. B: B is correct because hospice care is typically initiated when curative treatment is no longer effective and focuses on providing comfort and quality of life. D: D is correct because emotional support is crucial in end-of-life care to address the patient's psychological well-being and provide comfort. In summary, choice C is incorrect as it does not consider individual patient needs and preferences in end-of-life care.

Question 4 of 5

Family members are in the patient’s room when the patient has a cardiac arrest and the staff starts resuscitation measures. Which action should the nurse take next?

Correct Answer: C

Rationale: The correct answer is C because it involves patient-centered care and respects the family's preferences. By asking the family members whether they would prefer to remain in the patient's room or wait outside, the nurse acknowledges their needs and allows them to make an informed decision based on their comfort level. This empowers the family members and promotes a supportive environment during a stressful situation. Choice A is incorrect because it assumes that keeping the family in the room without their input is the best approach, which may not be the case for all families. Choice B is incorrect because asking the family to wait outside without considering their preferences may not be the most supportive action. Choice D is incorrect because it makes a blanket statement about patient comfort without considering individual family dynamics and preferences.

Question 5 of 5

The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate?

Correct Answer: D

Rationale: The correct answer is D because the patient is exhibiting Cheyne-Stokes breathing pattern characterized by periods of apnea followed by deep and rapid breathing. The nurse should document this pattern accurately. Option A is incorrect as suctioning is not indicated. Option B may worsen the respiratory pattern. Option C is not specifically related to addressing the breathing pattern.

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