Nursing Elites

1. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

• A. 52341
• B. 53241
• C. 35241
• D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

2. A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:

• A. Infection
• B. Hypothermia
• C. Anxiety
• D. Dehydration

Correct answer: D

Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.

3. When preparing to administer an IM injection that is irritating to the subcutaneous tissue, what is the best action to prevent tracking of the medication?

• A. Use a small gauge needle
• B. Apply ice on the injection site
• C. Administer at a 45° angle
• D. Use the Z-track technique

Correct answer: D

Rationale: The Z-track technique is the best action to prevent tracking of the medication when administering an IM injection that is irritating to the subcutaneous tissue. This technique involves pulling the skin to the side before administering the injection and then releasing the skin after the injection. By doing so, a zig-zag pathway is created, preventing the medication from leaking into the subcutaneous tissue and reducing irritation. Options A, B, and C are incorrect. Using a small gauge needle may not prevent tracking of the medication. Applying ice on the injection site or administering at a 45° angle does not specifically address preventing tracking of the medication in cases where the injection is irritating to the subcutaneous tissue.

4. When providing discharge teaching for a group of clients, a nurse should recommend a referral to a dietitian for which client?

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is the client who has gout and states, 'I can continue to eat anchovies on my pizza.' Gout is a condition that requires dietary modifications to manage symptoms. Anchovies are high in purines, which can exacerbate gout symptoms. Therefore, a referral to a dietitian is essential to provide appropriate dietary guidance for a client with gout. Clients on warfarin may need to monitor their vitamin K intake, particularly from foods like spinach. Clients taking spironolactone should be cautious about potassium-rich foods. Clients with osteoporosis should be educated on the proper administration of calcium supplements but do not necessarily need a dietitian referral for this specific statement.

5. A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

• A. Encourage the patient to walk in the hall alone
• B. Discourage the patient from walking in the hall for a few more days
• C. Accompany the patient for his walk
• D. Consult a physical therapist before allowing the patient to ambulate

Correct answer: C

Rationale: Accompanying the patient for his walk is the appropriate nursing intervention in this scenario to ensure his safety during his first ambulation. This allows the nurse to provide immediate assistance if needed and ensures the patient's well-being during this critical postoperative period.

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