Nursing Elites

1. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

• A. Tell the client’s family that they will be expected to stay overnight
• B. Apply restraints to the client
• C. Shout to the client
• D. Orient the client to the location of objects in the room

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.

2. A client sustained a crushing injury to his right arm during a car accident. He arrives to the emergency room complaining of numbness in his right hand. He has no other injuries. What should the nurse do first?

• A. Assess the right radial pulse
• B. Call the provider
• C. Administer pain medication
• D. Assess the right pedal pulse

Correct answer: A

Rationale: Assessing the radial pulse checks for adequate circulation and potential complications.

3. Unlicensed assistive personnel (UAP) is assisting a client in traction. Which of these actions requires immediate intervention?

• A. The unlicensed assistive personnel carefully lower the traction weights to hang freely
• B. The unlicensed assistive personnel provides small pillows to cushion the unaffected extremities
• C. The UAP carefully empties the indwelling catheter bag
• D. The UAP shows the client how to use the call light

Correct answer: A

Rationale: The correct answer is A because traction weights should hang freely to maintain their effectiveness. Choice B is incorrect because providing pillows to cushion unaffected extremities is appropriate. Choice C is also incorrect as emptying the catheter bag is a routine nursing task. Choice D is incorrect as teaching the client to use the call light promotes client safety.

4. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

5. A client has suffered from a femur fracture. What is the nurse's priority assessment?

• A. Pain
• B. Medication history
• C. Pedal pulses
• D. Socio-economic status

Correct answer: C

Rationale:

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