Nursing Elites

1. Which action should the nurse implement when using the confrontation technique during a vision exam?

• A. Use an ophthalmoscope to observe the client's pupil constriction when a strong light is shone on it.
• B. Stand behind the client and direct the client to report when an object enters the peripheral field of vision.
• C. Display a series of four cards with printing of varying sizes to the client and ask which card the client sees most clearly.
• D. Sit facing the client, look directly at the client's face, and move an object inward from the periphery.

Correct answer: D

Rationale: During a vision exam, the confrontation technique is used to assess peripheral vision. By sitting facing the client and moving an object inward from the periphery while looking directly at the client's face, the nurse allows the client to indicate when the object enters the visual field. This method helps in determining the extent of the client's peripheral vision accurately. Choices A, B, and C are incorrect as they do not describe the appropriate method for using the confrontation technique during a vision exam. Choice A involves using an ophthalmoscope to observe pupil constriction, choice B involves testing the peripheral field of vision without the confrontation technique, and choice C describes the Snellen eye chart test for visual acuity, which is not related to the confrontation technique.

2. What type of technique should the nurse observe when preparing to insert an indwelling catheter?

• A. Clean technique.
• B. Medical Asepsis.
• C. Isolation Protocol.
• D. Sterile Technique.

Correct answer: D

Rationale: When inserting an indwelling catheter, the nurse must observe sterile technique to minimize the risk of infections. Sterile technique involves using sterile equipment and maintaining a sterile field to prevent introducing pathogens into the urinary tract.

3. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

• A. Hyperphosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

4. The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?

• A. Dependent rubor.
• B. Absence of hair on the lower legs.
• C. Shiny, thin skin on the legs.
• D. Pain in the legs when walking.

Correct answer: D

Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.

5. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?

• A. On the left side of the bed facing the foot of the bed.
• B. On the right side of the bed facing the head of the bed.
• C. Perpendicular to the bed on the right side.
• D. Facing the bed on the left side of the bed.

Correct answer: A

Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.

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