Nursing Elites

1. Which action should the nurse implement when using the confrontation technique during a vision exam?

• A. Use an ophthalmoscope to observe the client's pupil constriction when a strong light is shone on it.
• B. Stand behind the client and direct the client to report when an object enters the peripheral field of vision.
• C. Display a series of four cards with printing of varying sizes to the client and ask which card the client sees most clearly.
• D. Sit facing the client, look directly at the client's face, and move an object inward from the periphery.

Correct answer: D

Rationale: During a vision exam, the confrontation technique is used to assess peripheral vision. By sitting facing the client and moving an object inward from the periphery while looking directly at the client's face, the nurse allows the client to indicate when the object enters the visual field. This method helps in determining the extent of the client's peripheral vision accurately. Choices A, B, and C are incorrect as they do not describe the appropriate method for using the confrontation technique during a vision exam. Choice A involves using an ophthalmoscope to observe pupil constriction, choice B involves testing the peripheral field of vision without the confrontation technique, and choice C describes the Snellen eye chart test for visual acuity, which is not related to the confrontation technique.

2. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

3. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?

• A. That means you have derived the maximum benefit, and the heat can be removed.
• B. Your blood vessels are becoming dilated and removing the heat from the site.
• C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
• D. The body's receptors adapt over time as they are exposed to heat.

Correct answer: D

Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.

4. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?

• A. Maintain the client in a lateral position using protective wrist and vest restraints.
• B. Position the client prone with a small pillow below the diaphragm.
• C. Raise the head and knee gatch when lying in a supine position.
• D. Transfer the client to a wheelchair close to the nursing station for observation.

Correct answer: B

Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.

5. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

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