Nursing Elites

1. Which nursing action prevents injury to a client's eye during the administration of eye drops?

• A. Holding the tip of the container above the conjunctival sac
• B. Rinsing the eye with saline before administration
• C. Placing the client in a supine position
• D. Pressing gently on the lower eyelid to open the eye

Correct answer: A

Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.

2. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?

• A. Examine personal values about the issue.
• B. Proceed with the transfusion if medically necessary.
• C. Refer the issue to the ethics committee.
• D. Administer the blood transfusion without informing the parents.

Correct answer: A

Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.

3. A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?

• A. Administer glucagon intramuscularly.
• B. Give the client 4 ounces of orange juice.
• C. Give the client a snack containing protein and carbohydrates.
• D. Encourage the client to rest until symptoms resolve.

Correct answer: B

Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.

4. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

• A. We need to document the exact medication you were taking because you might be allergic to it.
• B. You should take a different type of antibiotic this time.
• C. A rash is a common reaction and is not usually concerning.
• D. You can take the same antibiotic again if needed.

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

5. What should be done when caring for a client who died?

• A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
• B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
• C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
• D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.

Correct answer: A

Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.

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