Nursing Elites

1. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?

• A. Position the client 6.1 m (20 ft) away from the Snellen chart
• B. Instruct the client to follow a finger through the six cardinal positions of gaze
• C. Ask the client to cover their right eye during assessment of the left eye
• D. Hold a finger 46 cm (18 inches) away from the client's eye

Correct answer: B

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.

2. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

• A. “I have my own apartment now, but it’s not easy living away from my guardians.”
• B. “It’s been so stressful for me to even think about having my own family.”
• C. “I don’t even know who I am yet, and now I’m supposed to know what to do.”
• D. “My partner is pregnant, and I don’t think I have what it takes to be a good parent.”

Correct answer: D

Rationale: The statement about feeling unprepared to be a good parent indicates a significant concern that may need further assessment and support. This statement raises issues regarding the individual's readiness for parenthood and potential impact on the partner and the unborn child. Choices A, B, and C, while important, do not present immediate concerns regarding the well-being of another individual and do not raise potential risks that could have a direct impact on others.

3. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue measuring the client's vital signs every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Document the provider's directive in the medical record
• B. Notify the nursing manager
• C. Consult the facility's risk manager
• D. Complete an incident report

Correct answer: B

Rationale: In this scenario, the nurse is facing a critical situation with a client showing signs of hemorrhagic shock. The surgeon's directive of waiting for an hour without providing immediate intervention poses a risk to the client's well-being. The nurse should prioritize the client's safety and advocate for timely and appropriate care. Notifying the nursing manager is the correct action as it activates the chain of command to ensure that the client receives the necessary care promptly. Documenting the provider's directive, consulting the risk manager, or completing an incident report are not the immediate actions needed to address the client's deteriorating condition and ensure patient safety.

4. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

• A. Remove the gloves carefully and follow with hand hygiene
• B. Change gloves and continue
• C. Wash hands immediately without removing gloves
• D. Report the incident to the supervisor

Correct answer: A

Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.

5. The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?

• A. Mild nausea
• B. Hair loss
• C. Increased fatigue
• D. Fever of 101.5°F (38.6°C)

Correct answer: D

Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.

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