Nursing Elites

1. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

• A. Instruct the client to follow a finger through the six cardinal positions of gaze.
• B. Hold a finger 46 cm (18 in) away from the client’s eyes.
• C. Ask the client to cover their right eye during assessment of the left eye.
• D. Position the client 6.1 m (20 feet) away from the Snellen chart.

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

2. During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?

• A. Thin, parchment-like skin
• B. Loss of adipose tissue
• C. Dehydration
• D. Diminished skin elasticity

Correct answer: C

Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.

3. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?

• A. Obtain assistance and physically transfer the patient to the chair.
• B. Assist with ambulation and measure how far the patient walks.
• C. Give pain medication after ambulation so the patient will have a clear mind.
• D. Bring the patient to the cafeteria for group instruction on ambulation.

Correct answer: B

Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.

4. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

• A. The nurse opens the sterile field on a wet surface.
• B. The nurse turns away from the sterile field.
• C. The nurse uses a non-sterile glove to touch the sterile field.
• D. The nurse touches the edge of the sterile drape with her hand.

Correct answer: A

Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.

5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?

• A. Obtain client information
• B. Develop a plan of care
• C. Implement nursing interventions
• D. Evaluate the client's response to treatment

Correct answer: A

Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.

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