Nursing Elites

1. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

2. A client with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?

• A. Leafy green vegetables
• B. Red meat
• C. Fortified orange juice
• D. Whole grains

Correct answer: C

Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.

3. A nurse is preparing to administer a dose of warfarin. Which of the following should the nurse do?

• A. Check INR levels
• B. Administer it with food
• C. Monitor blood glucose
• D. Assess liver function

Correct answer: A

Rationale: The correct answer is to check INR levels. Before administering warfarin, it is crucial to check the INR levels to ensure they are within the therapeutic range. This helps to prevent complications such as bleeding or clotting. Choice B, administering it with food, is incorrect as warfarin should typically be taken on an empty stomach. Choice C, monitoring blood glucose, is unrelated to the administration of warfarin. Choice D, assessing liver function, is important but not the immediate action required before administering warfarin.

4. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

• A. Client placed in restraints for aggressive behavior
• B. A new client with a history of a 4.5 kg weight loss in the past two months
• C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
• D. Client who will be receiving his first ECT treatment today

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

5. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

• A. Polyuria
• B. Hypertension
• C. Pruritus
• D. Dry mouth

Correct answer: C

Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.

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