Nursing Elites

1. The client with a diagnosis of hepatitis is experiencing pruritus. Which would be the most appropriate nursing intervention?

• A. Suggest that the client take warm showers once a day.
• B. Add baby oil to the client's bath water.
• C. Apply powder to the client's skin.
• D. Suggest a cool-water rinse after bathing.

Correct answer: B

Rationale: Pruritus, or itching, in clients with hepatitis can be alleviated by adding moisturizing agents to bath water. Baby oil helps soothe and moisturize the skin, reducing dryness and itching. Warm showers, as in choice A, can be drying to the skin if taken too frequently, making it less suitable than adding oil to the bath water. Applying powder, as mentioned in choice C, can exacerbate dryness rather than alleviate it. Choice D suggests a cool-water rinse after bathing, which can help in retaining moisture and is less drying compared to hot water rinses.

2. What intervention should the nurse take for a client who has sustained a hyphema?

• A. Instruct the client to wear eye protectors in the future
• B. Keep the client at bed rest, typically with the head of the bed propped up
• C. Apply atropine eyedrops
• D. Apply an ice pack to the site of injury

Correct answer: B

Rationale: The correct intervention for a client who has sustained a hyphema is to keep them at bed rest, usually with the head of the bed raised. This positioning helps to reduce intraocular pressure and prevent further damage or rebleeding. Instructing the client to wear eye protectors in the future (Choice A) is not the immediate intervention required for a hyphema. Applying atropine eyedrops (Choice C) is not typically indicated for a hyphema. Applying an ice pack to the site of injury (Choice D) is not recommended for a hyphema as it can increase the risk of rebleeding. Therefore, the correct answer is to keep the client at bed rest.

3. When making an occupied bed, what is important for the nurse to do?

• A. keep the bed in the low position.
• B. use a bath blanket or top sheet for warmth and privacy
• C. constantly keep side rails raised on both sides.
• D. move back and forth from one side to the other when adjusting the linens.

Correct answer: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

4. Which of the following might be an appropriate nursing diagnosis for an epileptic client?

• A. Dysreflexia
• B. Risk for Injury
• C. Urinary Retention
• D. Unbalanced Nutrition

Correct answer: B

Rationale: The correct nursing diagnosis for an epileptic client would be 'Risk for Injury' as the client is prone to injuries during seizure activity, such as head trauma from falls. Epilepsy does not typically cause dysreflexia. While urinary retention may occur during or after a seizure, it is not a common nursing diagnosis related to epilepsy. 'Unbalanced Nutrition' is not a priority nursing diagnosis for an epileptic client compared to the immediate risk of injury during seizures.

5. The nurse is preparing to administer IV Vancomycin to a client. Which of the following nursing actions should be taken first?

• A. Performing a physical assessment prior to administration
• B. Obtaining the most recent lab values regarding renal function
• C. Reviewing peaks and troughs for the past few days
• D. Ensuring the client is not allergic to the medication

Correct answer: D

Rationale: Before administering any medication, including IV Vancomycin, it is crucial to ensure that the client is not allergic to the medication. This is the most critical action to prevent any potential allergic reactions. While performing a physical assessment is important, it may not be as time-sensitive as checking for allergies. Obtaining lab values related to renal function is also significant with Vancomycin due to its potential nephrotoxicity, but ensuring the client's safety by checking for allergies takes precedence. Reviewing peaks and troughs is important for monitoring drug levels, but it is a secondary step compared to checking for allergies prior to administration.

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