Nursing Elites

1. A client does not understand why vision loss due to glaucoma is irreversible. What is the best explanation?

• A. Once bacterial infection has caused damage, the tissue does not regenerate.
• B. Once retinal detachment occurs, it does not return to its normal state.
• C. Too many nerve fibers have become ischemic and died, so vision loss is permanent.
• D. Glaucoma always leads to permanent blindness.

Correct answer: C

Rationale: The correct answer is C. In glaucoma, the optic nerve damage due to high intraocular pressure leads to permanent vision loss because the nerve fibers do not regenerate. Choice A is incorrect as it discusses bacterial infection, not relevant to glaucoma. Choice B is incorrect because it refers to retinal detachment, not glaucoma. Choice D is incorrect because not all glaucoma cases lead to permanent blindness; vision loss can be prevented or slowed with treatment.

2. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

• A. Applying moisturizer to dry areas of the skin
• B. Massaging the client's reddened shoulders and heels
• C. Cleansing the skin routinely after soiling occurs
• D. Using a Hoyer lift for all transfers

Correct answer: B

Rationale:

3. A client is in skeletal traction. With the nurse's assessment, it is noted that the pairs appear red, swollen and there is purulent drainage. What action does the nurse take first?

• A. Collect a culture of the purulent fluid
• B. Cleanse the skin around the pins
• C. Administer an antibiotic
• D. Instruct the client to complete exercise of the affected extremity

Correct answer: A

Rationale:

4. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

• A. The UAP puts shoes on the client
• B. The UAP removes floor rugs and loose objects from the path
• C. The UAP walks to the side and slightly in front of the client
• D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

5. The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

• A. Deliver upward abdominal thrusts with a fisted hand
• B. Perform a blind finger sweep of the child's mouth
• C. Complete five rapid back blows between the shoulder blades
• D. Encourage the child to continue coughing

Correct answer: D

Rationale:

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