Nursing Elites

1. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?

• A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
• B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
• C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
• D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”

Correct answer: A

Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.

2. When moving a patient up in bed using a drawsheet with the help of another nurse, in which order will the nurses perform the steps, starting with the first one?

• A. Grasp the drawsheet firmly near the patient.
• B. Move the patient and drawsheet to the desired position.
• C. Position one nurse at each side of the bed.
• D. Place the drawsheet under the patient from shoulder to thigh.

Correct answer: C

Rationale: When moving a patient up in bed with a drawsheet and the assistance of another nurse, it is important to have one nurse positioned at each side of the bed initially. This allows for proper coordination and support during the patient movement. Placing the drawsheet under the patient from shoulder to thigh, grasping the drawsheet firmly near the patient, and moving the patient and drawsheet to the desired position follow after the nurses are positioned on each side of the bed. The correct sequence ensures a safe and coordinated approach to repositioning the patient in bed.

3. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?

• A. Provide a protein intake of 1.5 g/kg of body weight per day.
• B. Increase carbohydrate intake to 50% of daily calories.
• C. Administer high-dose vitamin supplements.
• D. Ensure a daily intake of 1000 calories.

Correct answer: A

Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.

4. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

• A. Notify the provider about the client's decision
• B. Proceed with the transport
• C. Prepare the surgical site
• D. Document the client’s statement

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

5. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Draw up each medication separately in the syringe.
• C. Push the syringe plunger gently if feeling resistance.
• D. Flush the tube with 15 mL of sterile water.

Correct answer: D

Rationale: The correct action the nurse should take when administering multiple medications to a client with an enteral feeding tube is to flush the tube with 15-30 mL of sterile water before and between medications, and 30-60 mL after the last medication. This helps prevent clogging and ensures each medication is delivered effectively. Choice A is incorrect as medications should not be dissolved in water for administration through an enteral feeding tube. Choice B is incorrect because each medication should be drawn up and administered separately to prevent any potential interactions. Choice C is incorrect as resistance while pushing the plunger may indicate a problem that needs to be addressed before continuing with the administration.

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