Nursing Elites

1. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

2. A client has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Take this medication in the morning to prevent insomnia.
• C. You should store this medication in the refrigerator.
• D. Take this medication with a full glass of water before breakfast.

Correct answer: D

Rationale: The correct statement the nurse should include is to take levothyroxine with a full glass of water before breakfast. This helps improve absorption and prevents gastrointestinal side effects. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect as insomnia is not a common side effect of levothyroxine. Choice C is also incorrect as levothyroxine does not need to be refrigerated.

3. Which electrolyte imbalance is commonly associated with furosemide?

• A. Hypokalemia
• B. Hyponatremia
• C. Hyperkalemia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, commonly causes the loss of potassium in the urine, leading to hypokalemia. This electrolyte imbalance can result in various complications such as cardiac arrhythmias and muscle weakness. Choice B, Hyponatremia, is not typically associated with furosemide use. Choice C, Hyperkalemia, is the opposite of the expected electrolyte imbalance caused by furosemide. Choice D, Hypercalcemia, is not a common side effect of furosemide.

4. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

5. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider?

• A. Potassium level 4.2 mEq/L
• B. Apical pulse 58/min
• C. Digoxin level 1 ng/ml
• D. Constipation for 2 days

Correct answer: B

Rationale: The correct answer is B. An apical pulse below 60/min indicates bradycardia, a potential sign of digoxin toxicity. The nurse should report this finding to the provider for further evaluation and possible adjustment of the digoxin dose. Choice A, a potassium level of 4.2 mEq/L, is within the normal range (3.5-5.0 mEq/L) and does not indicate toxicity. Choice C, a digoxin level of 1 ng/ml, is within the therapeutic range (0.5-2 ng/ml) and is not suggestive of toxicity. Choice D, constipation for 2 days, is not directly related to digoxin administration and would not require an immediate report to the provider.

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