Nursing Elites

1. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

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

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

2. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

• A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
• B. Use a mechanical lift
• C. Twist at the waist while holding the client
• D. Ask for assistance from another staff member

Correct answer: A

Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.

3. A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

• A. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she 'doesn't like him.'
• B. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions.
• C. The family of a client who has a terminal illness asks the provider not to tell the client the diagnosis.
• D. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications.

Correct answer: C

Rationale: The correct answer is C because an ethical dilemma involves conflicting moral principles. In this scenario, the family's request not to disclose the terminal diagnosis to the client raises the moral question of truth-telling and patient autonomy. Choice A does not present an ethical dilemma but rather a challenge in client compliance. Choice B involves professional responsibility and accountability, not an ethical dilemma. Choice D relates to financial concerns and insurance coverage, which do not constitute an ethical dilemma but rather a financial issue.

4. A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?

• A. Ptosis
• B. Hematuria
• C. Urticaria
• D. Nausea

Correct answer: C

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.

5. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

• A. Vomiting of dark emesis
• B. Complaints of throat pain
• C. Apical heart rate of 110
• D. Increased restlessness

Correct answer: D

Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.

Similar Questions