Nursing Elites

1. During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?

• A. "I have constant blurred vision."?
• B. "I can't see on my left side."?
• C. "I have to turn my head to see my room."?
• D. "I have specks floating in my eyes."?

Correct answer: C

Rationale: In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.

2. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?

• A. Counsel the woman to consent to HIV screening
• B. Perform tests for sexually transmitted diseases
• C. Discuss her high risk for cervical cancer
• D. Refer the client to a family planning clinic

Correct answer: A

Rationale: Counsel the woman to consent to HIV screening. The client's behavior places her at high risk for HIV. Testing is the first step in identifying and managing the risk of HIV infection. Early detection allows for timely interventions and better outcomes. While performing tests for sexually transmitted diseases (choice B) is important, addressing the immediate and potentially life-threatening risk of HIV takes precedence. Discussing the risk for cervical cancer (choice C) is not the priority at this time as HIV screening is more urgent. Referring the client to a family planning clinic (choice D) is not the immediate priority given the client's current high-risk behavior and the need to address the immediate threat of HIV infection.

3. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?

• A. Manage secretions by providing suction on a regular basis
• B. Cleanse the site daily with a mixture of povidone-iodine and water
• C. Avoid using tube ties to secure the tube
• D. None of the above

Correct answer: A

Rationale: Excess secretions from the tracheostomy tube can collect near the stomal opening and cause skin breakdown. Management of secretions through regular suctioning will keep the area clean and dry, minimizing skin irritation. Choice B, cleansing the site daily with povidone-iodine and water, is incorrect as it may lead to skin irritation due to the harshness of povidone-iodine. Choice C, avoiding tube ties to secure the tube, is also incorrect as securing the tube is essential for stability. Choice D, 'None of the above,' is incorrect as managing secretions through suctioning is crucial in preventing skin irritation.

4. The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?

• A. Stroke volume
• B. Cardiac output
• C. Venous pressure
• D. Left ventricular functioning

Correct answer: D

Rationale: The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.

5. While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

• A. Inspiratory crackles at the bases
• B. Expiratory wheezes in both lungs
• C. Abnormal lung sounds in the apices of both lungs
• D. Pleural friction rub in the right and left lower lobes

Correct answer: A

Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.

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