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. All of the following clients are in need of an emergency assessment except:

• A. a bleeding client who has an injury from falling debris.
• B. an unresponsive client.
• C. a client with an old injury.
• D. a pregnant woman with imminent delivery.

Correct answer: C

Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.

3. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.

4. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

• A. "I will assist you in arranging to have a medicine woman present."?
• B. "We do not allow medicine women in exam rooms."?
• C. "That does not make any difference in the outcome."?
• D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.

5. Which of the following is not an indication for pelvic ultrasonography?

• A. to measure uterine size
• B. to detect multiple pregnancies
• C. to measure renal size
• D. to detect foreign bodies

Correct answer: C

Rationale: Pelvic ultrasonography is commonly used to assess various conditions. Choices A, B, and D are all valid reasons for performing pelvic ultrasonography. Measuring uterine size helps evaluate conditions like fibroids, while detecting multiple pregnancies is essential for prenatal care. Furthermore, identifying foreign bodies can aid in diagnosing certain conditions. However, assessing renal size is typically not a primary reason for pelvic ultrasonography, making choice C the correct answer.

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