Nursing Elites

1. What intervention should the nurse take for a client who has sustained a hyphema?

• A. Instruct the client to wear eye protectors in the future
• B. Keep the client at bed rest, typically with the head of the bed propped up
• C. Apply atropine eyedrops
• D. Apply an ice pack to the site of injury

Correct answer: B

Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.

2. For which of the following conditions might blood be drawn to assess uric acid levels?

• A. asthma
• B. gout
• C. diverticulitis
• D. meningitis

Correct answer: B

Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.

3. When a physician removes a chest tube, which type of dressing is recommended to be placed over the site?

• A. transparent dressing
• B. colloidal dressing
• C. petrolatum gauze
• D. nonadherent dressing

Correct answer: C

Rationale: Petrolatum gauze is recommended to be placed over the site when a physician removes a chest tube because it forms an airtight seal, helping prevent air from entering the pleural space. This airtight seal is crucial to avoid complications such as a pneumothorax. Transparent dressing is not ideal for this purpose as it may not provide a sufficient seal due to its design. Colloidal dressing and nonadherent dressing are also not suitable for chest tube removal sites as they do not offer the same level of protection against air leakage and may not provide the necessary sealing properties.

4. A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

• A. Asking the client to wiggle their toes
• B. Medicating the client with the prescribed analgesic
• C. Realigning the client
• D. Removing some of the traction weights

Correct answer: C

Rationale: When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.

5. The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:

• A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
• B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
• C. request that the family have a seat in the station rather than stand while awaiting its loved one.
• D. request that the family wait for its loved one in the Emergency Department waiting room.

Correct answer: A

Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room. This ensures that sensitive information is not overheard. The report should be resumed only after the family has left the desk area to maintain confidentiality. Choice B is incorrect as bringing coffee does not address the issue of maintaining confidentiality. Choice C is incorrect as standing or sitting in the station does not prevent the family from overhearing confidential information. Choice D is incorrect as the Emergency Department waiting room is not the appropriate setting for waiting during a unit admission.

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