Nursing Elites

1. The nurse prepares a discharge plan for an older adult client following cataract extraction. What instructions should the nurse provide?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Irrigate the conjunctiva with saline before applying ointment.
• D. Read without direct lighting for 6 weeks.

Correct answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

2. The nurse is caring for a client with chronic heart failure who is receiving digoxin therapy. The nurse reviews the client's lab results and notes that the serum potassium level is 3.0 mEq/L. What action should the nurse take next?

• A. Administer a potassium supplement
• B. Notify the healthcare provider
• C. Hold the next dose of digoxin
• D. Increase dietary potassium intake

Correct answer: C

Rationale: In clients receiving digoxin therapy, low potassium levels can increase the risk of digoxin toxicity. Therefore, when the nurse notes a serum potassium level of 3.0 mEq/L, it is crucial to hold the next dose of digoxin. Notifying the healthcare provider is essential to ensure appropriate interventions, such as potassium supplementation, can be implemented. Administering a potassium supplement without healthcare provider guidance may lead to rapid potassium level changes and potential adverse effects. Increasing dietary potassium intake alone may not promptly address the low serum potassium level in this acute situation.

3. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

• A. White blood cell count
• B. Hemoglobin
• C. Serum creatinine
• D. Culture for sensitive organisms

Correct answer: D

Rationale: Purulent drainage suggests an infection at the wound site. Reviewing the culture and sensitivity results will guide appropriate antibiotic treatment by identifying the causative organisms and their antibiotic sensitivities. Elevated white blood cells indicate infection but do not specify the organism. Creatinine and hemoglobin values are unrelated to wound infections.

4. What does the nurse's signature on the client’s surgical consent form signify?

• A. The client voluntarily grants permission for the procedure to be done
• B. The client is competent to sign the consent without impairment of judgment
• C. The client understands the risks and benefits associated with the procedure
• D. The client has signed the form freely and voluntarily

Correct answer: A

Rationale: The nurse's signature on a surgical consent form signifies that the client voluntarily grants permission for the procedure to be done. This is the correct answer because the nurse's signature does not imply the client's competence, understanding of risks and benefits, or that the client signed the form freely and voluntarily. The nurse's role is to verify that the client has made an informed decision and is providing consent for the procedure.

5. A client with a deep vein thrombosis (DVT) is prescribed enoxaparin. What teaching should the nurse provide?

• A. Rotate injection sites to prevent bruising.
• B. Administer the injection in the abdomen only.
• C. Report any unusual bleeding or bruising.
• D. Avoid contact sports to prevent injury.

Correct answer: C

Rationale: The correct teaching for a client prescribed enoxaparin for deep vein thrombosis (DVT) is to report any unusual bleeding or bruising. Enoxaparin is an anticoagulant, and these symptoms could indicate excessive anticoagulation. Choice A is incorrect because with enoxaparin, injections are usually given in the abdomen, not rotated to different sites. Choice D is not directly related to the medication but is a general precaution for individuals at risk of injury.

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