Nursing Elites

1. A client presents at the clinic with blepharitis. What instructions should the nurse provide for home care?

• A. Use bilateral eye patches while sleeping to prevent injury to the eyes.
• B. Wear sunglasses when outdoors to prevent photophobia.
• C. Apply cold compresses to reduce inflammation.
• D. Apply warm moist compresses then gently scrub eyelids with diluted baby shampoo.

Correct answer: D

Rationale: The correct answer is D. Blepharitis is managed with warm moist compresses to help loosen debris and oils on the eyelids, followed by gentle scrubbing with a mild solution like diluted baby shampoo. This helps in controlling the condition. Choice A is incorrect as using eye patches while sleeping is not a standard recommendation for blepharitis. Choice B is incorrect as wearing sunglasses does not directly treat blepharitis but may help with light sensitivity. Choice C is incorrect as cold compresses are not typically used for blepharitis, as warm compresses are more effective in managing the condition.

2. A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?

• A. Widening pulse pressure
• B. Sudden drop in heart rate
• C. A decrease in urine output
• D. Elevated blood pressure and widening pulse pressure

Correct answer: D

Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.

3. A client with a history of congestive heart failure is admitted with shortness of breath. Which nursing intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer prescribed diuretic therapy.
• C. Monitor the client's oxygen saturation.
• D. Assess the client's level of consciousness.

Correct answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed is crucial in improving oxygenation in clients with congestive heart failure and shortness of breath by reducing venous return to the heart and decreasing fluid overload in the lungs. This intervention helps to alleviate the client's breathing difficulty. Administering diuretic therapy (Choice B) may be necessary but is not the initial priority. Monitoring oxygen saturation (Choice C) is important but should come after ensuring proper positioning. Assessing the client's level of consciousness (Choice D) is essential but is not the first intervention needed for a client experiencing respiratory distress.

4. A healthcare provider is assessing a client with a history of hypertension who is currently taking a diuretic. Which assessment finding is most important to report to the healthcare provider?

• A. Potassium level of 3.2 mEq/L
• B. Blood pressure of 148/90 mmHg
• C. Pulse rate of 62 beats per minute
• D. Blood glucose level of 130 mg/dl

Correct answer: A

Rationale: A potassium level of 3.2 mEq/L is low and places the client at risk for cardiac arrhythmias, requiring immediate intervention. Hypokalemia can result from diuretic use and can lead to serious complications such as irregular heart rhythms. Monitoring and correcting potassium levels are crucial in preventing adverse cardiac events. The other options, though important, do not pose an immediate life-threatening risk compared to the low potassium level.

5. A female client with ovarian cancer is receiving chemotherapy. Which laboratory result should the nurse report to the healthcare provider immediately?

• A. White blood cell count of 2,000/mm³
• B. Platelet count of 100,000/mm³
• C. Hemoglobin level of 10 g/dL
• D. Serum creatinine level of 1.5 mg/dL

Correct answer: A

Rationale: A white blood cell count of 2,000/mm³ is critically low and places the client at high risk for infection, requiring immediate intervention. Neutropenia, a low white blood cell count, is a common side effect of chemotherapy. A decreased white blood cell count compromises the immune system's ability to fight infections, making it a priority to address to prevent serious complications. Platelet count of 100,000/mm³ is relatively low but not as urgent as a severely low white blood cell count. Hemoglobin level of 10 g/dL is within the normal range for females and does not require immediate intervention. Serum creatinine level of 1.5 mg/dL is also within the normal range and does not pose an immediate threat to the client's health.

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