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 is receiving discharge teaching about a new prescription for ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with milk.
• B. I should expect my stools to turn black.
• C. I should avoid eating oranges while taking this medication.
• D. I will take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B. When taking ferrous sulfate, clients should expect their stools to turn black, which is a normal side effect due to the iron content. Choice A is incorrect because ferrous sulfate should not be taken with milk as it can decrease its absorption. Choice C is incorrect because vitamin C-rich foods like oranges can actually enhance the absorption of iron. Choice D is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption.

3. A client with diabetes mellitus receiving regular insulin should be monitored for which of the following manifestations of hypoglycemia?

• A. Bradycardia.
• B. Dry skin.
• C. Increased thirst.
• D. Increased urinary output.

Correct answer: A

Rationale: The correct answer is A, Bradycardia. Bradycardia is a common sign of hypoglycemia, which can occur as a complication of insulin therapy in clients with diabetes mellitus. Dry skin (choice B) is not typically associated with hypoglycemia. Increased thirst (choice C) and increased urinary output (choice D) are symptoms more commonly seen in conditions like hyperglycemia or diabetes insipidus, not hypoglycemia.

4. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid crowded places to reduce my risk of infection.
• B. I will take this medication on an empty stomach.
• C. I will stop taking this medication if I experience nausea.
• D. I will take this medication for 2 weeks and then stop.

Correct answer: A

Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.

5. A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

• A. There is no fluctuation in the water seal chamber.
• B. There is continuous bubbling in the suction control chamber.
• C. There is tidaling in the water seal chamber.
• D. The drainage system is positioned at the level of the client's chest.

Correct answer: A

Rationale: The correct answer is A: 'There is no fluctuation in the water seal chamber.' In a client with a pneumothorax being treated with a chest tube, the absence of fluctuation in the water seal chamber indicates that the lung has re-expanded. This finding suggests that there is no air leak from the lung into the pleural space. Choices B and C are incorrect because continuous bubbling in the suction control chamber or tidaling in the water seal chamber would suggest ongoing air leakage, indicating that the lung has not fully re-expanded. Choice D is also incorrect as the position of the drainage system does not directly indicate lung re-expansion.

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