Nursing Elites

1. On inspection, which client does the nurse suspect of having a visual impairment?

• A. The client whose sclera is white
• B. The client who has an intact blink reflex
• C. The client who is tilting their head
• D. The client with equal pupils

Correct answer: C

Rationale: Tilting the head may indicate a visual impairment as the client attempts to compensate for vision loss.

2. A goal for a client with impaired mobility is to prevent skin breakdown. What nursing intervention would best help the client meet this goal?

• A. Assist the client to orthopneic position
• B. Offer the client a bedpan for toileting
• C. Offer a protein-rich diet
• D. Turn the client every 2 hours

Correct answer: D

Rationale:

3. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

• A. Fistula
• B. Hemorrhage
• C. Evisceration
• D. infection

Correct answer: A

Rationale:

4. The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

• A. The client instills the prescribed number of eye drops into the conjunctival sac
• B. The client sets the cap to the eye drop container down in a manner that does not contaminate it
• C. The client touches the administration dropper her to the eye
• D. The client washes her hands before instilling the eye drops

Correct answer: C

Rationale:

5. A client has sustained an open fracture. What nursing intervention will best prevent osteomyelitis in this client?

• A. Delegate all client personal care to specific unlicensed assistive personnel
• B. Place the client in contact precautions
• C. Proper hand hygiene
• D. Administer pain medication

Correct answer: C

Rationale: Proper hand hygiene is crucial in preventing infections such as osteomyelitis in clients with open fractures. Keeping the hands clean helps reduce the risk of introducing harmful pathogens to the wound site. Delegating all client personal care to specific unlicensed assistive personnel (Choice A) is not appropriate as direct involvement in wound care is essential in preventing infections. Placing the client in contact precautions (Choice B) is not directly related to preventing osteomyelitis in this context. Administering pain medication (Choice D) is important for managing the client's pain but does not directly address the prevention of osteomyelitis.

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