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 nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

3. A client with gastroesophageal reflux disease (GERD) is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Lie down after meals to reduce discomfort.
• B. Limit fluid intake to 1 liter per day.
• C. Avoid eating spicy foods.
• D. Eat three large meals each day.

Correct answer: C

Rationale: The correct answer is C: 'Avoid eating spicy foods.' Spicy foods can exacerbate symptoms of GERD by irritating the esophagus and causing discomfort. It is important for clients with GERD to avoid spicy foods to help manage their condition. Choices A, B, and D are incorrect. A client with GERD should not lie down after meals as this can worsen symptoms, limiting fluid intake to only 1 liter per day may not be appropriate for everyone, and eating three large meals each day can put pressure on the stomach and worsen GERD symptoms.

4. A nurse is assessing a client who is experiencing acute alcohol withdrawal. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Tachycardia
• C. Hyperthermia
• D. Hypotension

Correct answer: B

Rationale: The correct answer is B: Tachycardia. In acute alcohol withdrawal, tachycardia is a common finding due to increased sympathetic activity. Bradycardia (Choice A) is less likely in this condition since the sympathetic nervous system is typically overactive. Hyperthermia (Choice C) is not a typical finding in acute alcohol withdrawal. Hypotension (Choice D) is less common compared to tachycardia in this situation.

5. A client practicing Orthodox Judaism informs the nurse they are observing the Passover holiday. Which action should the nurse include in the plan of care?

• A. Provide chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include consuming unleavened bread. This symbolizes the haste with which the Israelites left Egypt and the lack of time for bread to rise. Providing chicken with cream sauce (Choice A) is not aligned with Passover dietary restrictions. Avoiding serving fish with fins and scales (Choice B) is a general dietary law in Judaism but not specific to Passover. Similarly, avoiding foods containing lamb (Choice D) is not a specific requirement during Passover.

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