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 is admitted with a diagnosis of sepsis. Which assessment finding is most concerning to the nurse?

• A. Temperature of 101.5°F
• B. Heart rate of 110 beats per minute
• C. Respiratory rate of 24 breaths per minute
• D. Blood pressure of 90/60 mmHg

Correct answer: D

Rationale: A blood pressure of 90/60 mmHg in a client with sepsis is concerning for septic shock, a life-threatening condition that requires immediate intervention. Hypotension is a severe manifestation of sepsis that can lead to poor tissue perfusion and organ failure. While the other assessment findings such as an elevated temperature, increased heart rate, and respiratory rate are also common in sepsis, hypotension is particularly alarming as it indicates a critical state of shock and necessitates urgent medical attention.

3. A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

• A. Collect a clean-catch specimen
• B. Administer prescribed antibiotics
• C. Perform a bladder scan
• D. Increase the client's fluid intake

Correct answer: A

Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.

4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

5. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/7.50 mg. His vital signs are elevated from the previous hour: temperature 97.8 F, heart rate 102 beats per minute, respiration 20 breaths per minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left leg is larger than the right. Preoperatively, clopidogrel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete?

• A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
• B. The surgeon needs to see the client immediately to evaluate the situation.
• C. Left peripheral pulses were present only by Doppler pre-procedure.
• D. Client's history includes multiple back surgeries and chronic pain.

Correct answer: B

Rationale: The correct answer is B. Immediate evaluation by the surgeon is necessary due to the possibility of an internal hemorrhage, which is a life-threatening condition. Choice A is incorrect as lung status and oxygen saturation are not the priority in this situation. Choice C is not relevant to the current urgent issue. Choice D, while providing additional history, is not pertinent to the immediate concern of a potential internal hemorrhage post angioplasty and stent placement.

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