Nursing Elites

1. When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:

• A. Have the client sign the permit, as he verbalizes understanding.
• B. Witness the form after having the client sign it.
• C. Have his wife sign the form as she witnessed him saying he wants the surgery.
• D. Call the surgical area and explain the surgery will have to be cancelled.

Correct answer: D

Rationale: The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.

2. How does the family carry out its health care functions?

• A. The family provides very little preventive health care to its members at home.
• B. The family provides preventive health care to its members at home.
• C. The family pays for most health services.
• D. The family decides when and where to hospitalize its members.

Correct answer: B

Rationale: Families play a crucial role in providing preventive health care to their members at home. This includes activities such as promoting healthy lifestyles, ensuring vaccinations, scheduling regular check-ups, and intervening early when health issues arise. Therefore, the correct answer is that the family provides preventive health care to its members at home. Choices A, C, and D are incorrect because families are expected to actively engage in preventive health care practices rather than providing very little preventive care, solely paying for health services, or making hospitalization decisions. The focus is on the proactive role of families in maintaining the health of their members.

3. Health promotion activities are designed to help clients:

• A. reduce the risk of illness
• B. maintain maximal function
• C. promote healthy habits related to healthcare
• D. all of the above

Correct answer: D

Rationale: Health promotion activities encompass a broad range of interventions aimed at enhancing overall well-being. These activities not only focus on reducing the risk of illness but also on maintaining maximal function and promoting healthy habits related to healthcare. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all integral components of health promotion strategies, emphasizing the multidimensional approach required to support clients in achieving optimal health outcomes.

4. While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?

• A. Optic
• B. Abducens
• C. Olfactory
• D. Hypoglossal

Correct answer: C

Rationale: The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.

5. When removing hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
• B. Grasp the lens with a gentle pinching motion.
• C. Don sterile gloves before attempting the procedure.
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.

Correct answer: D

Rationale: When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.

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