Nursing Elites

1. A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

• A. Encourage the use of corrective lenses during the day
• B. Practice visual exercises that focus on a still object
• C. Alternate an eye patch from eye every 2 hours
• D. Teach techniques for scanning the environment

Correct answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

2. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

3. To evaluate the medication’s effectiveness in a client with a respiratory tract infection, which laboratory values should the nurse monitor?

• A. White blood cell (WBC) count
• B. Sputum culture and sensitivity
• C. Droplet precautions
• D. Protective environment

Correct answer: A

Rationale: The correct answer is A: White blood cell (WBC) count. Monitoring the WBC count helps assess the overall response to infection and the effectiveness of the antibiotic. Sputum culture and sensitivity (choice B) are also important to confirm if the antibiotic is targeting the specific pathogen. Choices C and D, droplet precautions and protective environment, are not laboratory values but rather infection control measures that do not directly evaluate the medication's effectiveness in treating the infection.

4. A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

• A. Discontinue the IO infusion
• B. Administer an analgesic via the IO site
• C. Elevate the extremity with the IO site
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.

5. An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

• A. obtain a serum potassium level
• B. administer the client's usual dose of insulin
• C. assess pupillary response to light
• D. Start an intravenous (IV) infusion of normal saline

Correct answer: D

Rationale: Administering IV fluids is crucial to address potential dehydration and electrolyte imbalances, especially if the client is unable to provide a clear history. Starting an IV infusion of normal saline will help rehydrate the client and address any electrolyte imbalances, which are common in clients with diabetes experiencing symptoms like abdominal cramping and vomiting. Obtaining a serum potassium level can be important but is not the priority when the client is showing signs of dehydration and confusion. Administering insulin should only be done after addressing hydration and electrolyte status. Assessing pupillary response to light is not the most critical action in this situation compared to addressing dehydration and potential electrolyte imbalances.

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