Nursing Elites

1. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

• A. Rotating application sites
• B. Limiting applications to the chest
• C. Rubbing it into the skin
• D. Covering it with a thin paper dressing

Correct answer: A

Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.

2. When assessing a client in crisis, what should the nurse prioritize?

• A. Allowing the client to work through independent problem-solving.
• B. Completing an in-depth evaluation of stressors and responses to the situation.
• C. Focusing on immediate stress reduction.
• D. Recommending ongoing therapy.

Correct answer: C

Rationale: When a client is in crisis, the nurse's priority is to focus on immediate stress reduction. Crisis intervention aims to stabilize the client in the present moment by addressing the most pressing issues. Allowing the client to work through independent problem-solving (Choice A) may not be appropriate during a crisis as they might need immediate support. Completing an in-depth evaluation of stressors (Choice B) is important but not the immediate priority during a crisis. Recommending ongoing therapy (Choice D) may be considered later, but the immediate focus should be on reducing the client's stress and stabilizing the situation.

3. The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?

• A. Notify the police department for investigation
• B. Report this behavior to the charge nurse
• C. Monitor the situation and document any suspicious activities
• D. Confront the patient care assistant immediately

Correct answer: B

Rationale: The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.

4. After talking to the nurse, the charge nurse should:

• A. Report the incident to the Board of Nursing
• B. File a formal reprimand
• C. Terminate the nurse
• D. Charge the nurse with a tort

Correct answer: B

Rationale: The appropriate action after discussing the problem with the nurse is to document the incident and file a formal reprimand. Reporting to the Board of Nursing may be necessary if the behavior persists or harm occurs to the client, but it is not the initial step. Termination should be considered if the issue continues despite warnings. Charging the nurse with a tort is not a suitable course of action in this situation as a tort refers to a wrongful act against a client or their belongings, not an appropriate disciplinary measure. Therefore, choices A, C, and D are incorrect.

5. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

Similar Questions