Nursing Elites

1. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

• A. Ptosis on the left eyelid.
• B. Nystagmus.
• C. Astigmatism.
• D. Exophthalmos.

Correct answer: A

Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.

2. The nurse is planning an immunization campaign targeting the children of migrant farm workers in the community. Which data should the nurse review before exploring solution options when developing this program plan?

• A. uncertain risks
• B. potential outcomes
• C. priority of solutions
• D. target population data

Correct answer: D

Rationale: Correct. Before designing an immunization campaign for the children of migrant farm workers, the nurse should review target population data. This includes understanding the specific demographics, health needs, and challenges faced by this population to create a tailored and effective program. Reviewing uncertain risks (choice A) may not provide actionable insights for program development. Considering potential outcomes (choice B) is important but comes after understanding the target population. Evaluating the priority of solutions (choice C) is premature without knowing the specific characteristics and needs of the target population.

3. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?

• A. provide the client with 4 ounces of orange juice
• B. call 911 to summon emergency assistance
• C. check the client for lacerations or fractures
• D. assess the client's blood sugar level

Correct answer: C

Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.

4. When caring for a client with a chest tube, which intervention is most important to include in the plan of care?

• A. Maintain continuous suction on the chest tube.
• B. Clamp the chest tube during client movement.
• C. Ensure that the chest tube is clamped for at least 8 hours each day.
• D. Keep the collection chamber below the level of the chest.

Correct answer: D

Rationale: Keeping the collection chamber below the level of the chest is crucial in caring for a client with a chest tube. This positioning helps ensure proper drainage of fluids and prevents complications such as backflow of drainage into the chest cavity. Option A is incorrect as continuous suction can lead to excessive drainage and tissue damage. Option B is incorrect as clamping the chest tube during client movement can cause a buildup of pressure and compromise proper drainage. Option C is incorrect because clamping the chest tube for extended periods can impede the drainage process, leading to potential complications.

5. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate intervention?

• A. Serum sodium of 140 mEq/L.
• B. Serum osmolality of 280 mOsm/kg.
• C. Weight gain of 2 pounds in 24 hours.
• D. Serum sodium of 130 mEq/L.

Correct answer: D

Rationale: The corrected answer is D. A serum sodium level of 130 mEq/L indicates hyponatremia, which requires immediate intervention in a client with SIADH. Hyponatremia can lead to serious complications such as seizures, coma, and cerebral edema. Choices A, B, and C are not the most critical findings in a client with SIADH. While a serum sodium of 140 mEq/L is within the normal range, a decrease to 130 mEq/L is concerning and requires prompt action to prevent complications.

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