Nursing Elites

1. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

• A. Maintain prescribed eye drop regimen
• B. Avoid frequent eye pressure measurements
• C. Wear prescription glasses
• D. Eat a diet high in carotene

Correct answer: A

Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.

2. A patient presents with severe chest pain radiating to the left arm. Which of the following diagnostic tests is the priority?

• A. Complete blood count (CBC)
• B. Electrocardiogram (ECG)
• C. Chest X-ray
• D. Serum electrolytes

Correct answer: B

Rationale: In a patient presenting with severe chest pain radiating to the left arm, the priority diagnostic test is an Electrocardiogram (ECG) to assess for myocardial infarction. An ECG can quickly identify changes indicative of ischemia or infarction, guiding prompt management. A Complete Blood Count (CBC) may provide some information but is not the primary test for evaluating chest pain related to myocardial infarction. A Chest X-ray can be useful in assessing lung pathologies or certain cardiac conditions; however, it does not provide immediate information on myocardial infarction, making it a secondary option in this scenario. Serum electrolytes may become important in later stages but do not offer immediate insights into myocardial infarction. Therefore, they are a lower priority compared to obtaining an ECG for timely diagnosis and intervention.

3. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?

• A. Liquids as desired.
• B. Small, easily digested meals.
• C. Three regular meals per day.
• D. Nothing by mouth.

Correct answer: B

Rationale: During the acute phase of myocardial infarction, it is recommended to provide small, easily digested meals for the client. This type of diet is better tolerated as it reduces the workload on the heart, allowing for easier digestion and absorption of nutrients. Choice A, 'Liquids as desired,' may not provide adequate nutrition and may not be well-balanced. Choice C, 'Three regular meals per day,' may be too heavy for the client's weakened condition. Choice D, 'Nothing by mouth,' is not appropriate as the client still requires essential nutrients for recovery.

4. A client with nephrotic syndrome is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Proteinuria
• B. Hypoalbuminemia
• C. Lipiduria
• D. All of the above

Correct answer: D

Rationale: Nephrotic syndrome is characterized by glomerular damage, leading to proteinuria (excessive protein in the urine), hypoalbuminemia (low levels of albumin in the blood), and lipiduria (lipids in the urine). These manifestations are key indicators of nephrotic syndrome. Edema, often severe, is also common due to decreased plasma oncotic pressure from hypoalbuminemia. The correct answer is 'All of the above' because all three manifestations are associated with nephrotic syndrome. Dehydration is not a typical finding in nephrotic syndrome as it is more commonly associated with fluid retention and edema. Dysuria is a symptom of cystitis, not nephrotic syndrome. CVA tenderness is more indicative of inflammatory changes in the kidney rather than nephrotic syndrome.

5. In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?

• A. Shallow open ulcer with a red-pink wound bed.
• B. A deep pocket of infection and necrotic tissues.
• C. An area of erythema that is painful to touch.
• D. Visible subcutaneous tissue with sloughing.

Correct answer: A

Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.

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