Nursing Elites

1. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

2. Since children with attention deficit hyperactivity disorder (ADHD) take medication for long periods of time, side effects must be considered. How often should children be assessed for side effects of the drug therapy?

• A. Every 2 months
• B. Every 4 months
• C. Every 6 months
• D. Every 8 months

Correct answer: C

Rationale: Children with ADHD who are on long-term medication therapy should be assessed for side effects every 6 months. This timeframe allows healthcare providers to monitor the effects of the medication and make any necessary adjustments. Checking every 2 months (Choice A) may be too frequent and not practical for routine monitoring, while checking every 4 or 8 months (Choices B and D) may lead to missing potential side effects or delays in addressing them.

3. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?

• A. Increase your intake of potassium-rich foods.
• B. Restrict your fluid intake to 1 liter per day.
• C. Avoid salt substitutes containing potassium.
• D. Weigh yourself once a week.

Correct answer: A

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.

4. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

• A. Assist with personal care, but leave oral care for the nurse to complete.
• B. Provide a soft bristle brush for the client to use during oral care.
• C. Use alcohol-based mouthwash to clean the ulcers.
• D. Apply an antifungal cream to the mouth ulcers.

Correct answer: B

Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.

5. During the initial assessment of an older male client with obesity and diabetes who develops intermittent claudication, which additional information obtained by the nurse is most significant?

• A. Smokes 1.5 packs of cigarettes daily.
• B. Exercises regularly.
• C. Has a high-fat diet.
• D. Consumes alcohol daily.

Correct answer: A

Rationale: The correct answer is A: 'Smokes 1.5 packs of cigarettes daily.' Smoking is a significant risk factor for peripheral arterial disease, a condition that can lead to intermittent claudication. The nicotine and other chemicals in cigarettes can damage blood vessels, leading to reduced blood flow and increased risk of developing circulation problems. Choices B, C, and D are less significant in the context of intermittent claudication. Regular exercise, a high-fat diet, and daily alcohol consumption may have health implications, but they are not as directly linked to the development of intermittent claudication in the presence of obesity, diabetes, and smoking.

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