Nursing Elites

1. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

• A. The client instills the prescribed number of eye drops into the conjunctival sac
• B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
• C. The client touches the administration dropper her to the eye
• D. The client washes her hands before instilling the eye drops

Correct answer: C

Rationale:

2. What nursing intervention is appropriate for a client with systemic lupus erythematous (SLE)?

• A. Intense cold therapy to the extremities
• B. Encourage ultraviolet (UV) light exposure
• C. Administer topical hydrocortisone
• D. Administer antibiotics

Correct answer: C

Rationale:

3. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

• A. The UAP puts shoes on the client
• B. The UAP removes floor rugs and loose objects from the path
• C. The UAP walks to the side and slightly in front of the client
• D. The UAP uses a transfer (gait) belt

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

4. The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

• A. The client refused her pain medication this morning and is doing physical therapy.
• B. The client reports a minor headache and states she takes an over-the-counter pain pill at home.
• C. The client reports intermittent flatus and minor abdominal discomfort.
• D. The client has paresthesia in her fingers and intense increasing pain in her shoulder.

Correct answer: D

Rationale: In a client with rheumatoid arthritis one day after shoulder surgery, paresthesia in the fingers and intense increasing pain in the shoulder could indicate nerve compression or damage, which are serious post-operative complications. This situation requires immediate attention from the provider to prevent further complications and ensure appropriate management. The other options, such as refusing pain medication, reporting a minor headache, or experiencing minor abdominal discomfort, are important but not as urgent or indicative of potential serious complications as paresthesia in the fingers and intense increasing pain in the shoulder.

5. A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5 cm by 3 cm. the nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

• A. Stage III pressure injury
• B. A stage II pressure injury
• C. A non-staging pressure injury
• D. Stage IV pressure injury

Correct answer: D

Rationale:

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