Nursing Elites

1. A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?

• A. Use eye drops to soothe dryness
• B. Avoid rubbing the eye
• C. Sleep on the side of the affected eye
• D. Avoid lying on the affected side

Correct answer: D

Rationale: After cataract surgery, it is essential to avoid lying on the affected side to reduce pressure and promote healing. Sleeping on the side of the affected eye (Choice C) may increase pressure on the eye, leading to complications. While using eye drops to soothe dryness (Choice A) is generally recommended postoperatively, it is not as crucial as avoiding pressure on the eye. Rubbing the eye (Choice B) should be avoided to prevent irritation and potential damage, but it is not as critical as avoiding pressure on the affected eye.

2. What are the risk factors for pressure ulcer development?

• A. Immobility and poor nutrition
• B. Obesity and diabetes
• C. Dehydration and malnutrition
• D. Use of assistive devices and prolonged bedrest

Correct answer: A

Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.

3. A client has developed phlebitis at the IV site. What should the nurse do first?

• A. Apply a warm compress to the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the IV site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.

4. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?

• A. 20 mL
• B. 15 mL
• C. 25 mL
• D. 10 mL

Correct answer: A

Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.

5. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
• B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
• C. A client who has epidural analgesia and weakness in the lower extremities.
• D. A client who has a hip fracture and a new onset of tachypnea.

Correct answer: D

Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.

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