Nursing Elites

1. Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?

• A. Use a metal eye shield on the operative eye during the day.
• B. Administer eye ointment before applying eye drops.
• C. Sexual activities may be resumed after returning home.
• D. Light housekeeping is safe to do, but avoid heavy lifting.

Correct answer: D

Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.

2. A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

• A. Notify social services immediately if suspected elderly abuse is present.
• B. Discuss the need for mental health counseling with the daughter.
• C. Explain to the client the importance of taking better care of herself.
• D. Collect further data to determine whether self-neglect is occurring.

Correct answer: D

Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.

3. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:

• A. Within 10 to 15 minutes after the injection.
• B. 1 hour after the injection.
• C. At any time, because timing of meals with lispro injections is unnecessary.
• D. 2 hours before the injection.

Correct answer: A

Rationale: The correct answer is to eat within 10 to 15 minutes after the injection. Insulin lispro, also known as Humalog, is a rapid-acting insulin that starts working very quickly. Eating shortly after the injection helps match the food intake with the insulin action, reducing the risk of hypoglycemia. Choice B is incorrect because waiting 1 hour after the injection may lead to a mismatch between insulin activity and food intake. Choice C is incorrect as timing meals with lispro injections is essential to optimize glycemic control. Choice D is incorrect as eating 2 hours before the injection is not in alignment with the rapid action of insulin lispro and may lead to fluctuations in blood sugar levels.

4. In a patient with asthma, which of the following is the most important indicator of respiratory function?

• A. Oxygen saturation.
• B. Respiratory rate.
• C. Arterial blood gases.
• D. Peak expiratory flow rate.

Correct answer: D

Rationale: The peak expiratory flow rate is the most important indicator of respiratory function in asthma because it measures how quickly air can be exhaled, reflecting the severity of airflow limitation. Oxygen saturation (Choice A) is important in assessing oxygenation, but it does not directly reflect respiratory function. Respiratory rate (Choice B) can provide information on breathing patterns but does not quantify airflow limitation. Arterial blood gases (Choice C) give information about gas exchange but are not as specific for assessing asthma control and severity as peak expiratory flow rate.

5. A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to:

• A. Administer epinephrine.
• B. Inform the physician.
• C. Administer oxygen.
• D. Inform the client that the procedure is almost over.

Correct answer: B

Rationale: The correct immediate action for the nurse to take in this situation is to inform the physician. The symptoms described - nausea, tingling, and dyspnea - indicate a potential allergic reaction to the contrast dye used in the arteriogram. It is crucial to notify the physician promptly so that further assessment and appropriate interventions can be initiated. Administering epinephrine without physician guidance can be dangerous as the physician needs to evaluate the severity of the reaction and determine the necessary treatment. Administering oxygen may be needed but should be done under the physician's direction. Informing the client that the procedure is almost over is not a priority when the client is experiencing symptoms of a possible allergic reaction.

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