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 client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which finding requires immediate intervention?

• A. Oxygen saturation of 88%
• B. Respiratory rate of 24 breaths per minute
• C. Heart rate of 90 beats per minute
• D. Productive cough with green sputum

Correct answer: D

Rationale: In a client with COPD admitted with pneumonia, a productive cough with green sputum indicates a potential bacterial infection. Green sputum is commonly associated with bacterial pneumonia, which requires immediate intervention with appropriate antibiotics. Monitoring oxygen saturation, respiratory rate, and heart rate are essential in COPD patients, but the presence of green sputum suggests an urgent need for targeted treatment to address the underlying infection. Oxygen saturation of 88% is concerning but may not directly indicate the need for immediate intervention in the absence of other critical symptoms. Respiratory rate of 24 breaths per minute and a heart rate of 90 beats per minute are within normal limits and may not be indicative of an acute issue requiring immediate intervention in this context.

3. A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding transmission of anthrax should the nurse provide to the group?

• A. Infection is acquired when anthrax spores enter a host.
• B. Mature anthrax bacteria live dormant on inanimate objects.
• C. Spores cannot survive for extended periods outside a living host.
• D. Anthrax is transmitted by respiratory droplets from person to person.

Correct answer: A

Rationale: The correct answer is A: Infection is acquired when anthrax spores enter a host. Anthrax is primarily transmitted through spores entering the body, either through the skin, inhalation, or ingestion. Person-to-person transmission of anthrax is extremely rare and not a significant mode of transmission. Choices B and C are incorrect because mature anthrax bacteria do not live dormant on inanimate objects, and spores can survive for extended periods outside a living host. Choice D is incorrect as anthrax is not transmitted by respiratory droplets from person to person.

4. A client with a history of myocardial infarction is prescribed aspirin therapy. Which instruction should the nurse include in the client's teaching plan?

• A. Take aspirin with food.
• B. Take aspirin at the same time every day.
• C. Avoid taking aspirin with alcohol.
• D. Discontinue aspirin if you experience ringing in your ears.

Correct answer: C

Rationale: The correct instruction for the nurse to include in the client's teaching plan is to avoid taking aspirin with alcohol. Combining aspirin with alcohol can increase the risk of gastrointestinal bleeding and other complications. Taking aspirin with food helps reduce stomach upset, but it is not the most crucial instruction in this scenario. While taking aspirin at the same time every day can help with consistency, it is not as critical as avoiding alcohol. Discontinuing aspirin if experiencing ringing in the ears is important to address potential side effects, but it is not directly related to preventing complications when combining with alcohol.

5. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

• A. Supine with the foot of the bed raised.
• B. On the left side with legs elevated.
• C. On the right side with legs elevated.
• D. Prone with head elevated.

Correct answer: A

Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.

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