Nursing Elites

1. A nurse is caring for a client who is postoperative following cataract surgery. The client reports that they do not want to wear their eye shield. What should the nurse do?

• A. Allow the client to make their own decision
• B. Explain the importance of wearing the eye shield
• C. Remove the eye shield and assess the eye
• D. Encourage the client to discuss their concerns

Correct answer: B

Rationale: The correct answer is B: Explain the importance of wearing the eye shield. It is important for the nurse to educate the client on the reasons why wearing the eye shield is crucial post cataract surgery, such as protecting the eye from injury and promoting proper healing. This empowers the client with knowledge and helps them make an informed decision. Choice A is incorrect because the nurse should provide necessary information to ensure the client's safety. Choice C is incorrect as removing the eye shield without proper justification can compromise the client's recovery. Choice D is also incorrect as discussing concerns should come after the client is educated on the importance of the eye shield.

2. While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?

• A. Increase the IV flow rate
• B. Discontinue the infusion
• C. Elevate the limb
• D. Apply a cold compress

Correct answer: B

Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.

3. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?

• A. Wear non-sterile gloves
• B. Apply sterile gloves over non-sterile gloves
• C. Change gloves if the sterile solution splashes onto the sterile field
• D. Cover the sterile field with a sterile drape

Correct answer: C

Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.

4. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?

• A. Increased fluid intake
• B. Urinary incontinence
• C. Poor nutrition
• D. Immobility

Correct answer: B

Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.

5. While documenting client care, which entry should the nurse identify as an example of implementing client care?

• A. Documenting the client's pain level
• B. Monitoring the client's urine output
• C. Assessing the client's range of motion
• D. Contacting the provider to report client findings

Correct answer: D

Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.

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