Nursing Elites

1. A nurse is assessing a newborn who is 1-day old and receiving phototherapy for jaundice. Which action should the nurse take?

• A. Feed the infant glucose water every 2 hours.
• B. Ensure the newborn wears a diaper.
• C. Keep the infant's head covered with a cap.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to keep the infant's head covered with a cap. This helps regulate the newborn's body temperature during phototherapy. Option A, feeding the infant glucose water every 2 hours, is incorrect because it is not a standard intervention for newborns receiving phototherapy. Option B, ensuring the newborn wears a diaper, may be necessary for hygiene but is not directly related to phototherapy. Option D, applying lotion to the newborn every 4 hours, is unnecessary and not indicated for managing jaundice or phototherapy.

2. A nurse is caring for a client who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1500 mL per day.
• B. Avoid massaging the affected extremity to relieve pain.
• C. Do not apply cold packs to the client's affected extremity.
• D. Elevate the client's affected extremity when in bed.

Correct answer: D

Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.

3. When should healthcare professionals perform hand hygiene?

• A. Before and after patient contact
• B. Before and after performing procedures
• C. After using the restroom
• D. After touching contaminated surfaces

Correct answer: A

Rationale: Healthcare professionals should perform hand hygiene before and after patient contact to prevent the spread of infections. While choices B, C, and D are also important times to practice hand hygiene, they are not as crucial as before and after patient contact because patient contact poses a higher risk of transmitting infections.

4. What should be monitored when administering opioids to a patient?

• A. Monitor blood pressure
• B. Monitor respiratory rate
• C. Monitor heart rate
• D. Monitor oxygen saturation

Correct answer: B

Rationale: When administering opioids, monitoring the respiratory rate is crucial to detect any signs of respiratory depression, which is a serious side effect of opioid use. Monitoring blood pressure, heart rate, and oxygen saturation are important parameters to assess a patient's overall condition, but they are not the primary focus when administering opioids.

5. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.

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