Nursing Elites

1. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?

• A. Wearing gloves during the procedure
• B. Using a sterile solution
• C. Irrigating from the inner to the outer canthus
• D. Positioning the client's head properly

Correct answer: A

Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.

2. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

• A. Wear cotton clothing to avoid static electricity.
• B. Avoid using any electrical appliances.
• C. Keep the oxygen tank away from heat sources.
• D. Use only a specific type of nasal cannula.

Correct answer: A

Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.

3. A healthcare professional is reviewing a client’s medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the healthcare professional should identify that this combination is likely to result in which of the following effects?

• A. Decreased therapeutic effects of cimetidine
• B. Increased risk of imipramine toxicity
• C. Decreased risk of adverse effects of cimetidine
• D. Increased therapeutic effects of imipramine

Correct answer: B

Rationale: When cimetidine decreases the metabolism of imipramine, it leads to an increased concentration of imipramine in the body, which can result in imipramine toxicity. This increased risk of toxicity is the likely effect of this drug interaction. Choice A is incorrect because cimetidine's effect on imipramine metabolism does not impact the therapeutic effects of cimetidine. Choice C is incorrect because the interaction does not decrease the risk of adverse effects of cimetidine. Choice D is incorrect as the increased concentration of imipramine can lead to toxicity, not increased therapeutic effects.

4. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. ''Incident report completed.''
• B. ''Client climbed over the bedrails.''
• C. ''Client found lying on the floor.''
• D. ''Client was trying to get out of bed.''

Correct answer: C

Rationale: The correct answer is C: ''Client found lying on the floor.'' In this situation, the nurse should document factual, objective information without making assumptions. Stating that the client was found lying on the floor directly reflects what was observed. Choice A, ''Incident report completed,'' is not a statement about the incident itself and does not provide relevant information. Choice B, ''Client climbed over the bedrails,'' introduces unnecessary speculation and assumption which should be avoided when documenting incidents. Choice D, ''Client was trying to get out of bed,'' focuses on the client's behavior rather than the objective observation of the client's position when found.

5. The caregiver is assessing an 8-month-old child with atonic cerebral palsy. Which statement from the caregiver supports the presence of this problem?

• A. When I place my finger in the left hand, the baby does not respond with a grasp.
• B. My baby does not seem to track objects when I move toys in front of their face.
• C. When it thundered loudly last night, the baby did not even startle.
• D. When I place the baby in a supine position, that's how I find the baby.

Correct answer: D

Rationale: The statement 'When I place the baby in a supine position, that's how I find the baby' supports the presence of atonic cerebral palsy. In this type of cerebral palsy, the child may have poor muscle tone, making it difficult for them to roll from a back-lying position. This inability to roll indicates a lack of muscle tone, which is a characteristic feature of atonic cerebral palsy. Choices A, B, and C do not directly relate to the muscle tone issues typical of atonic cerebral palsy. Choice A focuses on a lack of grasp response, which may suggest motor issues but not specifically atonic cerebral palsy. Choice B refers to visual tracking, and choice C is about the startle reflex, neither of which are defining characteristics of atonic cerebral palsy.

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