Nursing Elites

1. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

2. A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?

• A. No. When the lesions have disappeared, you may stop the nystatin.
• B. Yes. You should continue it for the full 7 days.
• C. No. Thrush is a self-limiting disorder, and nystatin is given for complete treatment.
• D. Yes. The medication should be refilled for a second week of therapy.

Correct answer: B

Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection. Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush. Choice C is inaccurate as nystatin is not just for comfort but for effective treatment. Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.

3. A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What is the most important instruction the nurse should provide?

• A. Stop taking insulin until feeling better
• B. Increase fluid intake to prevent dehydration
• C. Consume high-carbohydrate foods only
• D. Check blood glucose levels frequently

Correct answer: D

Rationale: The correct answer is to instruct the client to check blood glucose levels frequently. During illness, such as nausea and vomiting, managing blood glucose levels is crucial in clients with type 1 diabetes mellitus. Monitoring blood glucose levels frequently helps in adjusting insulin doses appropriately, preventing complications like hyperglycemia or hypoglycemia. Choice A is incorrect because stopping insulin abruptly can lead to serious complications. Choice B is important but not the most critical in this scenario. Choice C is incorrect as high-carbohydrate foods may further affect blood glucose levels negatively.

4. What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

• A. A history of diarrhea following each feeding
• B. Gastric pain evidenced by vigorous crying
• C. Poor appetite due to a poor sucking reflex
• D. An olive-shaped mass right of the midline

Correct answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

5. What is the main characteristic of cystic fibrosis?

• A. Multiple upper respiratory infections
• B. An underproduction of exocrine glands
• C. Excessive, thick mucus
• D. An overproduction of thin mucus

Correct answer: C

Rationale: The main characteristic of cystic fibrosis is the production of excessive, thick mucus. This thick mucus leads to blockages in the airways, digestive system, and other organs. Choice A is incorrect because while individuals with cystic fibrosis are more prone to respiratory infections, the main characteristic is the mucus production. Choice B is incorrect as cystic fibrosis is characterized by the overproduction, not underproduction, of exocrine glands. Choice D is also incorrect as the mucus produced in cystic fibrosis is thick, not thin.

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