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. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

3. A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:

• A. Kawasaki disease
• B. rheumatic disease
• C. lupus erythematosus
• D. fifth disease

Correct answer: D

Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks. Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children. Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.

4. A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?

• A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
• B. Ask a medical assistant.
• C. Call the nurse in charge of the day shift.
• D. Ask the police officers who brought the client to the center.

Correct answer: A

Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.

5. A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?

• A. Submerge the end of the chest tube in a bottle of sterile water
• B. Clamp the chest tube with a Kelly clamp
• C. Call the health care provider
• D. Instruct the client to inhale and hold his breath

Correct answer: A

Rationale: When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.

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