Nursing Elites

1. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?

• A. Assess the client’s most recent blood glucose levels.
• B. Check the client’s hemoglobin A1C level.
• C. Check the client’s blood pressure for signs of hypertension.
• D. Examine the client’s feet for signs of neuropathy.

Correct answer: A

Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.

2. A mother reports that she has been applying triple antibiotic ointment for her son's athlete's foot for two days with no improvement. What should the nurse instruct?

• A. Continue using the ointment and keep the area clean.
• B. Stop using the ointment and encourage the feet to be dried completely.
• C. Apply a different antifungal medication instead.
• D. Reapply the ointment twice a day for a longer period.

Correct answer: B

Rationale: Antibiotic ointment is ineffective against athlete's foot, which is a fungal infection. The nurse should instruct the mother to stop using the ointment and ensure the feet are dried properly, as moisture exacerbates fungal infections. Applying a different antifungal medication is a valid option, but addressing the moisture issue by drying the feet completely is the immediate priority. Continuing to use the antibiotic ointment or reapplying it for a longer period will not treat the fungal infection effectively.

3. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?

• A. Question the client about the frequency of falls.
• B. Request the client to lie still during the assessment.
• C. Ask how often episodes of sundowning are experienced.
• D. Assist the client with values clarification about end-of-life care.

Correct answer: A

Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.

4. An adult client with a broken femur reports muscle spasms. What action should the nurse implement while awaiting surgery?

• A. Check the client's most recent electrolyte levels.
• B. Administer a PRN dose of muscle relaxant.
• C. Reduce the weight on the traction device.
• D. Encourage oral fluid intake to relieve muscle tension.

Correct answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.

5. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?

• A. Severe tenderness and guarding
• B. Slight discomfort upon palpation
• C. A sensation of fullness
• D. No symptoms unless the gallbladder is extremely inflamed

Correct answer: A

Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.

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