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 client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?

• A. Cough deeply after each use.
• B. Take a deep breath and hold for 10 seconds.
• C. Breathe in slowly and deeply to raise the ball or piston.
• D. Exhale forcefully before using the spirometer.

Correct answer: C

Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.

3. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

• A. Place the wheelchair at a 45-degree angle to the bed
• B. Position the wheelchair parallel to the bed
• C. Place the wheelchair in front of the bed
• D. Have the client stand and pivot into the wheelchair

Correct answer: A

Rationale: Placing the wheelchair at a 45-degree angle to the bed is the correct technique for transferring a client who is unable to walk from bed to a wheelchair. This positioning facilitates a safer and easier transfer by providing more space for maneuvering and reducing the distance the client needs to be moved. Positioning the wheelchair parallel to the bed (Choice B) may make the transfer more challenging due to limited space and a longer distance to move the client. Placing the wheelchair in front of the bed (Choice C) may not provide an optimal angle for the transfer. Having the client stand and pivot into the wheelchair (Choice D) is not appropriate for a client who is unable to walk and could increase the risk of falls or injuries during the transfer.

4. A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?

• A. Hypoglycemia
• B. Hyperglycemia
• C. Hypertension
• D. Hyperkalemia

Correct answer: B

Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.

5. During a follow-up visit, a home health nurse notices that a client with a gastrostomy tube, who receives intermittent feedings and medications, has developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

• A. The client’s caregiver washes out the feeding bag once every 24 hours with warm water.
• B. The client’s caregiver washes out the feeding bag with hot water every 24 hours.
• C. The client’s caregiver changes the feeding bag every 48 hours.
• D. The client’s caregiver adds water to the formula before administration.

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag once every 24 hours with warm water can lead to bacterial growth due to inadequate cleaning, potentially causing diarrhea. Hot water, as in choice B, can also promote bacterial growth, which is not desirable. Changing the feeding bag every 48 hours, like in choice C, is within an acceptable timeframe and is unlikely to be a cause of diarrhea. Adding water to the formula before administration, as in choice D, is a common practice to dilute the formula but is not typically associated with causing diarrhea in this scenario.

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