Nursing Elites

1. The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?

• A. "How did you get those bruises?"?
• B. "Did someone grab you by your arms?"?
• C. "Do you fall often?"?
• D. "What did you bump against?"?

Correct answer: B

Rationale: The correct answer is asking, "Did someone grab you by your arms?"? This question is direct and addresses the possibility of abuse, which is crucial when dealing with suspected abuse cases. It is important to ask direct questions in a sensitive and non-accusatory manner to gather information. Choice A is too general and may not prompt a disclosure of abuse. Choice C assumes falling as the cause without addressing abuse directly. Choice D is vague and does not specifically inquire about potential abuse, making it less effective in identifying abuse cases compared to the correct choice.

2. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

3. Before administering Theodur to a 10-year-old being treated for asthma, the nurse should check the:

• A. Urinary output
• B. Blood pressure
• C. Pulse
• D. Temperature

Correct answer: C

Rationale: The correct answer is to check the pulse. Theodur is a bronchodilator used in asthma treatment, and one of the side effects is tachycardia (increased heart rate). Therefore, it is essential to assess the pulse rate before administering Theodur to monitor for any potential tachycardia. Checking urinary output (Choice A), blood pressure (Choice B), and temperature (Choice D) are not directly related to the immediate side effects of bronchodilators like Theodur in this context, making them unnecessary assessments.

4. A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:

• A. mild anxiety.
• B. moderate anxiety.
• C. severe anxiety.
• D. a panic attack.

Correct answer: C

Rationale: The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.

5. The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:

• A. administer both medications simultaneously.
• B. give the medications sequentially, and flush well between them.
• C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug.
• D. start one medication now and begin the other medication in 2-4 hours.

Correct answer: B

Rationale: A client with an infection needs both antibiotics as soon as possible. However, the pH of ampicillin is 8-10, and the pH of gentamicin is 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent interaction. Choice C is incorrect because the nurse, not the physician or pharmacy, should determine the correct administration sequence. Consulting with the pharmacist is appropriate if uncertain. Choice D is incorrect because delaying the second medication by several hours can slow the treatment of the client's infection, as both antibiotics are needed promptly to address the infection effectively. Therefore, the correct action is to give the medications sequentially and flush well between them to prevent any potential interactions.

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