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 nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

• A. Airway
• B. Blood pressure
• C. Surgical site
• D. Level of consciousness

Correct answer: A

Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.

3. A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

• A. I keep having nightmares about my upcoming surgery.
• B. I feel more energetic than I did before.
• C. I have been making plans for the future.
• D. I am looking forward to starting my new treatment.

Correct answer: A

Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.

4. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?

• A. Determine the client's sleep and activity patterns
• B. Obtain a prescription for the client to take when stressed
• C. Refer the client for a sleep study and neurological follow-up
• D. Teach coping strategies to use when feeling stressed

Correct answer: A

Rationale: Assessing the client's sleep and activity patterns is crucial in understanding the factors contributing to the sleep difficulties and headaches. By evaluating these patterns, the nurse can identify triggers, stressors, and lifestyle habits that may be impacting the client's sleep quality and overall well-being. This assessment will guide the nurse in formulating an appropriate care plan tailored to the client's specific needs. Option B is not appropriate as it focuses solely on providing medication without addressing underlying issues. Option C is premature as a thorough assessment should precede any referrals for specialized studies. Option D, while important, should come after understanding the client's sleep patterns to provide more targeted coping strategies.

5. During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?

• A. Counsel the client on medication adherence.
• B. Assess the client for medication reactions.
• C. Compile a list of the client's current medications.
• D. Evaluate the client's understanding of medications.

Correct answer: C

Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.

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