Nursing Elites

1. What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

• A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
• B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
• C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
• D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.

Correct answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.

2. What is the most common side effect of diuretics such as furosemide (Lasix)?

• A. Hypokalemia.
• B. Hyperkalemia.
• C. Hypernatremia.
• D. Hyponatremia.

Correct answer: A

Rationale: The correct answer is 'Hypokalemia.' Diuretics like furosemide increase the excretion of potassium, leading to hypokalemia as a common side effect. Hyperkalemia (choice B) is the opposite condition characterized by high potassium levels, which is not typically associated with furosemide use. Hypernatremia (choice C) is increased sodium levels, while hyponatremia (choice D) is decreased sodium levels, neither of which are the most common side effects of furosemide. Therefore, choice A is the best answer.

3. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?

• A. Request an order for IV epinephrine to treat anaphylactic shock.
• B. Slow the infusion to 10 mg/min and observe the patient closely.
• C. Stop the infusion and obtain an order for a BUN and serum creatinine.
• D. Suspect Stevens-Johnson syndrome and notify the provider immediately.

Correct answer: B

Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.

4. After educating a client with stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I will limit my total intake of fluids.
• B. I must avoid drinking alcoholic beverages.
• C. I must avoid drinking caffeinated beverages.
• D. I shall try to lose about 10% of my body weight.

Correct answer: A

Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.

5. Which of the following symptoms would a healthcare provider expect to find in a patient with hyperkalemia?

• A. Muscle cramps.
• B. Hypertension.
• C. Bradycardia.
• D. Tachycardia.

Correct answer: D

Rationale: Tachycardia is the correct symptom to expect in a patient with hyperkalemia. Hyperkalemia, or high potassium levels in the blood, can affect the electrical activity of the heart. Increased potassium levels can lead to changes in the heart's rhythm, potentially causing tachycardia (rapid heart rate) or other cardiac arrhythmias. Muscle cramps (choice A) are not typically associated with hyperkalemia. Hypertension (choice B) is not a common symptom of hyperkalemia; in fact, high potassium levels can sometimes cause low blood pressure. Bradycardia (choice C), or a slow heart rate, is usually not a primary symptom of hyperkalemia; instead, hyperkalemia tends to be associated with faster heart rates or arrhythmias.

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