Nursing Elites

1. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

• A. Anxiety related to loss of vision and potential failure to regain vision.
• B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
• C. Acute pain related to tissue injury and decreased circulation to the eye.
• D. Risk for infection related to the eye injury.

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

2. A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?

• A. Administer pain medication to the patient.
• B. Inform the patient's family about the procedure in person.
• C. Decrease the temperature of the blood to be given.
• D. Increase the temperature of the blood to be given.

Correct answer: D

Rationale: In patients with a history of cardiac arrhythmia, warming the blood before transfusion can help prevent additional arrhythmias. Cold blood can lead to arrhythmias and should be avoided. Administering pain medication (Choice A) is not directly related to the safe administration of blood. Informing the patient's family in person (Choice B) is important but not the immediate action required for safe transfusion. Decreasing the temperature of the blood to be given (Choice C) would increase the risk of cardiac arrhythmia, contrary to the goal of ensuring patient safety.

3. A client is experiencing chest pain. Which statement made by the client indicates angina rather than a myocardial infarction?

• A. "I became dizzy when I stood up."?
• B. "I was nauseated and began vomiting."?
• C. "The pain started in my chest and stopped after I sat down."?
• D. "The pain began with a migraine and progressed to numbness in my left arm."?

Correct answer: B

Rationale: The correct answer is: '"The pain started in my chest and stopped after I sat down."? This statement suggests angina rather than a myocardial infarction because angina is typically triggered by exertion or stress and relieved by rest. Nausea and vomiting (Choice B) are more commonly associated with a myocardial infarction. Choices A and D are not typical symptoms of either angina or myocardial infarction.

4. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?

• A. A weight greater than 10 lbs. should be used.
• B. The line of pull is upward at an angle.
• C. The line of pull is straight
• D. A weight greater than 20 lbs. should be used.

Correct answer: C

Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.

5. A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?

• A. Aspiration noted on a honey-thick diet
• B. Pain felt during a bowel movement
• C. Pain felt in the left upper quadrant
• D. Right shoulder pain

Correct answer: B

Rationale: The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.

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