Nursing Elites

1. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

2. The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?

• A. Pull the client toward you, and pivot him on the unaffected limb.
• B. Pull the client toward you, and pivot him on the affected limb.
• C. Push the client toward the bed, and pivot him on the affected limb.
• D. Stand the client on both legs, and push him toward the bed.

Correct answer: A

Rationale: When transferring a client from a wheelchair to the bed, the correct procedure is to pull the client toward you, which reduces workload force. By pivoting the client on the unaffected limb, strength is maintained to support the affected limb while moving towards the bed. Choice A is correct because it ensures a safe and effective transfer technique. Choices B, C, and D are incorrect as they involve incorrect positioning and movements that could potentially harm the client or increase the risk of injury. Pulling the client towards you puts less strain on your back and reduces the risk of injury. Pivoting on the unaffected limb ensures better support for the client's affected limb during the transfer process.

3. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

• A. Telling the client that she needed to ask these questions before signing the informed consent for surgery
• B. Contacting the surgeon and requesting that she visit the client to answer her questions
• C. Informing the client that she has the right to cancel the surgical procedure if she wishes
• D. Telling the client that it is her surgeon's responsibility to explain the procedure

Correct answer: B

Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery. Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension. Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.

4. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

5. A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.

• A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
• B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
• C. go get the surgeon to answer all of the client's questions
• D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed

Correct answer: D

Rationale: In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.

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