Nursing Elites

1. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

• A. Ptosis on the left eyelid.
• B. Nystagmus.
• C. Astigmatism.
• D. Exophthalmos.

Correct answer: A

Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.

2. A community health nurse is developing a program to address the opioid crisis in the community. Which intervention should the nurse prioritize?

• A. Providing education on the dangers of opioid use
• B. Distributing naloxone kits to first responders
• C. Offering support groups for individuals struggling with addiction
• D. Partnering with local pharmacies to monitor prescriptions

Correct answer: B

Rationale: The correct answer is B: Distributing naloxone kits to first responders. Naloxone is a medication that can rapidly reverse opioid overdose, potentially saving lives. In an opioid crisis scenario, providing naloxone kits to first responders equips them to act swiftly in emergencies. Choice A, providing education on the dangers of opioid use, is important but may not be as immediately life-saving as naloxone distribution. Choice C, offering support groups, is valuable for long-term recovery but may not address the acute crisis of overdoses. Choice D, partnering with local pharmacies to monitor prescriptions, focuses on prevention rather than immediate response to overdoses.

3. The healthcare provider is caring for a client with a chest tube following thoracic surgery. Which intervention should the healthcare provider include in the plan of care?

• A. Clamp the chest tube for 30 minutes every 2 hours.
• B. Milk the chest tube to ensure patency.
• C. Keep the drainage system at the level of the chest.
• D. Ensure that the chest tube is not clamped or kinked.

Correct answer: D

Rationale: Ensuring that the chest tube is not clamped or kinked is essential to maintain proper drainage and prevent complications. Clamping the chest tube can lead to a buildup of pressure in the pleural space, causing potential harm to the client. Milking the chest tube is not recommended as it can cause damage to the delicate tubing. Keeping the drainage system at the level of the chest ensures proper drainage by gravity, preventing backflow of fluids, but ensuring the tube is not clamped or kinked takes precedence in this scenario.

4. The community health nurse is planning a series of educational courses about the healthcare system and meeting healthcare needs for the community center. Which adjunct issue should the nurse address for a group of older adults?

• A. peer concerns
• B. adult daycare
• C. retirement issues
• D. vocational concerns

Correct answer: C

Rationale: Retirement often brings specific healthcare needs and concerns that are crucial to address for older adults. While peer concerns and adult daycare could be important aspects to consider, retirement issues are more directly related to the unique healthcare needs and challenges faced by older adults. Vocational concerns are typically more relevant to individuals who are still actively engaged in the workforce, rather than retired older adults.

5. The healthcare provider is assessing a client with a suspected pulmonary embolism. Which finding requires immediate intervention?

• A. Chest pain.
• B. Shortness of breath.
• C. Tachycardia.
• D. Cyanosis.

Correct answer: D

Rationale: Cyanosis is a late sign of hypoxemia and indicates severe oxygen deprivation, necessitating immediate intervention in a client with a suspected pulmonary embolism. Chest pain, shortness of breath, and tachycardia are also concerning symptoms in pulmonary embolism; however, cyanosis signifies critical oxygen deficiency and warrants urgent attention to prevent further complications.

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