Nursing Elites

1. Which technique or method is used to determine whether or not the patient has an irregular pulse?

• A. Apical pulse
• B. Inspection
• C. Auscultation
• D. Percussion

Correct answer: A

Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.

2. A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

• A. File an incident report.
• B. Ask the client about his injuries with the son present.
• C. Ask the client's son to go to the waiting area.
• D. Treat and discharge the client

Correct answer: C

Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.

3. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?

• A. Store opened bottles of normal saline in a refrigerator for up to 48 hours.
• B. Return unused supplies from the bedside to the unit's supply stock.
• C. Wait to dispose of sharps containers until they are completely full.
• D. Use clean gloves rather than sterile gloves for colostomy care.

Correct answer: D

Rationale: Using clean gloves rather than sterile gloves for colostomy care is a cost-effective measure without compromising care quality. This choice helps in reducing costs without compromising patient safety. Storing opened bottles of normal saline in a refrigerator for up to 48 hours (Choice A) may lead to contamination risks. Returning unused supplies to the unit's supply stock (Choice B) can be inefficient and lead to potential waste. Waiting to dispose of sharps containers until they are completely full (Choice C) may pose safety hazards and not directly impact cost savings.

4. A patient is admitted to the emergency department with hypovolemia. Which IV solution should the nurse anticipate administering?

• A. 3% sodium chloride
• B. 10% dextrose in water
• C. 0.45% sodium chloride
• D. Lactated Ringer's solution

Correct answer: D

Rationale: Lactated Ringer's solution is the most suitable IV solution for a patient with hypovolemia. It is a balanced crystalloid solution containing electrolytes such as sodium, chloride, potassium, calcium, and lactate, which closely resemble the body's natural fluids. This solution helps to restore intravascular volume and electrolyte balance in hypovolemic patients. Choice A, 3% sodium chloride, is a hypertonic solution used for specific situations like severe hyponatremia or cerebral edema, not typically for hypovolemia. Choice B, 10% dextrose in water, is a hypertonic solution primarily used for providing calories and free water, not for volume expansion. Choice C, 0.45% sodium chloride, is a hypotonic solution used for conditions like hypernatremia or as maintenance fluid, not for hypovolemia.

5. Which statement about glaucoma is true and accurate?

• A. Acute angle-closure glaucoma is an ocular emergency.
• B. Acute angle-closure glaucoma leads to the loss of peripheral vision and tunnel vision.
• C. Primary open-angle glaucoma leads to eye pain, nausea, and vomiting, blurry vision, and halos.
• D. Bubbles are implanted to protect the retina from glaucoma.

Correct answer: A

Rationale: The correct answer is A: 'Acute angle-closure glaucoma is an ocular emergency.' Acute angle-closure glaucoma is indeed considered an ocular emergency that requires immediate attention to prevent vision loss. Choice B is incorrect because acute angle-closure glaucoma commonly presents with symptoms like severe eye pain, headache, blurred vision, and halos around lights. Choice C is incorrect as these symptoms are more indicative of acute angle-closure glaucoma rather than primary open-angle glaucoma. Choice D is incorrect since bubbles are not typically used to protect the retina from glaucoma; treatment usually involves medications, laser therapy, or surgery to manage intraocular pressure.

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