Nursing Elites

1. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

• A. Capillary refill of 4 seconds
• B. 7.5 cm (3 in) diameter bruise on the ankle
• C. Warts on the affected ankle
• D. 2+ pitting edema

Correct answer: A

Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.

2. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain radiate to other areas?
• C. Does the pain increase with movement?
• D. Can you rate your pain on a scale of 1 to 10?

Correct answer: A

Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.

3. A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?

• A. Assess the client for orthostatic hypotension
• B. Obtain a gait belt
• C. Ensure the client has proper footwear
• D. Ask the client to perform range-of-motion exercises

Correct answer: A

Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.

4. Which nursing action prevents injury to a client's eye during the administration of eye drops?

• A. Holding the tip of the container above the conjunctival sac
• B. Rinsing the eye with saline before administration
• C. Placing the client in a supine position
• D. Pressing gently on the lower eyelid to open the eye

Correct answer: A

Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.

5. The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.

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