Nursing Elites

1. A nurse is preparing to administer a pneumococcal vaccine. Which of the following should the nurse verify?

• A. Client's allergy to eggs
• B. Client's current medications
• C. Client's vaccination history
• D. Client's blood pressure

Correct answer: C

Rationale: The correct answer is C: Client's vaccination history. Before administering a pneumococcal vaccine, the nurse should verify the client's vaccination history to ensure they are due for the vaccine. Verifying the vaccination history helps prevent unnecessary vaccinations and ensures that the client receives the appropriate immunization at the right time. Choices A, B, and D are not directly related to the administration of the pneumococcal vaccine. Checking for allergies to eggs may be important for other vaccines, but it is not specifically relevant to pneumococcal vaccination. The client's current medications and blood pressure are important for general health assessment but are not directly related to verifying the need for a pneumococcal vaccine.

2. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?

• A. Encourage the client to focus on a distant object.
• B. Apply a warm compress to the client’s eyes.
• C. Recommend alternating eye patches during the day.
• D. Administer artificial tears.

Correct answer: C

Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.

3. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

4. While caring for a newborn under phototherapy lights, what is an appropriate nursing action?

• A. Ensure an eye shield is covering the eyes
• B. Apply lotion to the exposed skin
• C. Offer glucose water between feedings
• D. Discontinue breastfeeding during treatment

Correct answer: A

Rationale: The correct answer is to ensure an eye shield is covering the eyes. This action is essential to protect the newborn's eyes from the bright light used in phototherapy. Applying lotion to the exposed skin (Choice B) is not necessary and may interfere with the treatment. Offering glucose water between feedings (Choice C) is not indicated and may not be appropriate for a newborn undergoing phototherapy. Discontinuing breastfeeding during treatment (Choice D) is not recommended as breastfeeding should be continued unless contraindicated.

5. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

• A. Response to pain medication
• B. Review of ongoing discharge plan
• C. Recent physical changes
• D. All of the above

Correct answer: D

Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.

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