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. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

3. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?

• A. Cleanse the stoma with hydrogen peroxide and water.
• B. Apply a moisture barrier cream to the peristomal skin.
• C. Measure the stoma using a stoma guide.
• D. Use a dry gauze pad to clean the stoma.

Correct answer: C

Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.

4. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?

• A. Administer oxygen via non-rebreather mask.
• B. Administer furosemide (Lasix) IV push.
• C. Insert a Foley catheter to monitor urine output.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.

5. What is the most effective way to implement a teaching plan?

• A. Teach the information that the learner wants to learn first.
• B. Streamline the teaching plan to include only essential information.
• C. Present to the learner all the necessary information to meet the objectives.
• D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

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