Nursing Elites

1. What type of injury is associated with acute hyphema?

• A. orthopedic
• B. eye
• C. insect sting or snakebite
• D. gynecological trauma

Correct answer: B

Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.

2. The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, "Will you promise me you will be my nurse tomorrow?"? Which response is most appropriate?

• A. "Yes, I promise you I will be your nurse during my shift tomorrow."?
• B. "You will need to speak to my supervisor about this request."?
• C. "While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request."?
• D. "Because of confidentiality, I cannot discuss tomorrow's assignments with you."?

Correct answer: D

Rationale: The most appropriate response is to maintain confidentiality regarding work assignments. It is crucial to uphold patient privacy and not disclose information about staff schedules or assignments. Choices A, B, and C involve promising or redirecting the patient, which is not suitable in this situation. Choice D respects confidentiality and is the most professional response in this scenario.

3. Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?

• A. simplify medication administration
• B. measure accurate input and output
• C. prevent accumulation of fluids and gas
• D. facilitate collection of specimens

Correct answer: C

Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting. Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.

4. A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?

• A. Assisting a client with dysphagia in eating
• B. Ambulating a client with Parkinson's disease
• C. Providing hygiene to a client with dementia
• D. Assisting a client with an above-the-knee amputation in showering

Correct answer: A

Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.

5. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

• A. measure intake and output.
• B. check albumin levels.
• C. monitor glucose levels.
• D. increase enteral feeding.

Correct answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

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