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. When assessing a client's risk for elimination impairment, which of the following factors is least relevant?

• A. current medications
• B. ambulation abilities
• C. family history
• D. hydration status

Correct answer: C

Rationale: When assessing a client's risk for elimination impairment, family history is the least relevant factor to consider. Current medications can affect elimination functions through side effects, ambulation abilities can impact mobility to access toileting facilities, and hydration status directly influences urinary output and bowel function. Family history, although providing some context, does not have a direct impact on the client's current risk of elimination impairment.

3. A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:

• A. document the current functional status
• B. have the physician fax a report to the receiving facility
• C. copy appropriate parts of the medical record for transport to the receiving facility
• D. phone a report to the facility

Correct answer: B

Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.

4. Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:

• A. Outbreak of Asian flu.
• B. Chemical exposure.
• C. Bacterial pneumonia.
• D. Allergic reaction.

Correct answer: B

Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.

5. The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?

• A. Explain to the client's family member that the procedure may be delayed further.
• B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
• C. Allow the client's family member to serve as the interpreter.
• D. Ask if a phone-service interpreting service is available to expedite the client preparation.

Correct answer: C

Rationale: Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care. Choice A is a better option as it involves communication with the family member to manage expectations. Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication. Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.

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