Nursing Elites

1. To ensure safety while administering a nitroglycerine patch, what should the nurse do?

• A. Wear gloves
• B. Shave the area where the patch will be applied
• C. Wash the area thoroughly with soap and rinse with hot water
• D. Apply the patch to the buttocks

Correct answer: A

Rationale: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.

2. What are appropriate nursing strategies to assist a client in maintaining a sense of self?

• A. Addressing the client by their first name when interacting with them
• B. Treating the client with dignity
• C. Explaining procedures to the client regardless of their attentiveness
• D. Encouraging the use of personal items to foster a sense of identity

Correct answer: B

Rationale: Maintaining a sense of self is crucial for clients in healthcare settings. Treating the client with dignity is a fundamental nursing principle that helps preserve the client's self-worth and identity. Addressing the client by their first name when interacting with them is a way to show respect, but it alone may not significantly contribute to maintaining their sense of self. Explaining procedures to the client, regardless of their attentiveness, is essential for informed consent and autonomy, empowering them in their care. Encouraging the use of personal items can foster a sense of identity as these items often hold personal significance and emotional value for the client, thus supporting their sense of self; therefore, discouraging their use would be counterproductive in maintaining a client's sense of self.

3. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

4. A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?

• A. Use a magnet to remove the object.
• B. Rinse the eye thoroughly with saline.
• C. Cover both eyes with paper cups.
• D. Administer eye drops immediately.

Correct answer: C

Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.

5. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

• A. Take the blood pressure, pulse, and temperature
• B. Ask the client to rate his pain on a scale of 0-5
• C. Watch the client's facial expression
• D. Ask the client if he is in pain

Correct answer: B

Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.

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