Nursing Elites

1. While caring for a newborn under phototherapy lights, which of the following is an appropriate nursing action?

• A. Ensure the eye shield is covering the eyes.
• B. Apply lotion to the exposed skin.
• C. Offer glucose water between feedings.
• D. Discontinue breastfeeding during treatment.

Correct answer: A

Rationale: The correct answer is to ensure the eye shield is covering the eyes. Protecting the newborn's eyes from exposure to direct light is crucial during phototherapy to prevent potential eye damage. Applying lotion to the exposed skin (choice B) is not recommended as it can interfere with the effectiveness of the phototherapy. Offering glucose water between feedings (choice C) is not necessary and may not be suitable for a newborn undergoing treatment. Discontinuing breastfeeding during treatment (choice D) is not recommended as breast milk provides essential nutrients and hydration for the newborn, and breastfeeding should continue unless contraindicated by a specific medical condition.

2. What is the most important nursing assessment post-surgery?

• A. Monitor vital signs
• B. Monitor blood pressure
• C. Monitor the surgical site
• D. Monitor the incision site

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs encompass various parameters like blood pressure, heart rate, respiratory rate, and temperature. Monitoring vital signs helps in early detection of complications such as hemorrhage, infection, or shock. While monitoring the surgical site and incision site are also essential post-surgery, monitoring vital signs takes precedence as it provides a broader assessment of the patient's overall condition. Monitoring blood pressure is part of vital sign assessment and is not the most comprehensive assessment post-surgery.

3. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

• A. Apply hydrocolloid dressing
• B. Provide wound debridement
• C. Change the dressing daily
• D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

4. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

5. What is the priority nursing action for a patient with respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The priority nursing action for a patient with respiratory distress is to administer oxygen. Oxygen therapy is crucial in improving oxygenation levels and relieving respiratory distress, making it the top priority intervention. Repositioning the patient, administering bronchodilators, or providing chest physiotherapy may be necessary interventions depending on the underlying cause, but ensuring adequate oxygen supply should take precedence in addressing respiratory distress.

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