Nursing Elites

1. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• 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 while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

2. A client is being taught about patient-controlled analgesia (PCA). Which statement should be included in the teaching?

• A. The PCA will deliver a double dose of medication when you push the button twice.
• B. Continuous PCA infusion is designed to allow fluctuating plasma medication levels.
• C. You should push the button before physical activity to allow maximum pain control.
• D. You can adjust the amount of pain medication you receive by pushing on the keypad.

Correct answer: D

Rationale: The correct statement to include in the teaching about PCA is that the client can adjust the amount of pain medication they receive by pushing on the keypad. This empowers the client to control their pain management effectively. Choice A is incorrect because PCA systems are programmed to prevent double dosing when the button is pressed multiple times in quick succession. Choice B is incorrect as continuous PCA infusion aims to maintain a steady plasma medication level. Choice C is incorrect because it is not necessary to push the button before physical activity to ensure maximum pain control; the client should use the PCA as needed for pain relief.

3. A client with a new diagnosis of hypertension is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should avoid eating foods high in potassium.
• B. I will check my blood pressure at least once a week.
• C. I should increase my intake of dairy products.
• D. I should exercise for 30 minutes at least 5 days a week.

Correct answer: D

Rationale: The correct answer is D. Exercising for 30 minutes at least 5 days a week helps manage hypertension by promoting cardiovascular health. Statements A, B, and C are incorrect. Avoiding foods high in potassium is not necessary unless specifically advised by a healthcare provider. Checking blood pressure once a week is not frequent enough for effective monitoring. Increasing dairy product intake is not a recommended approach to managing hypertension.

4. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

• A. Perform perineal care before the procedure.
• B. Apply sterile gloves before cleansing the perineal area.
• C. Place the client in a supine position.
• D. Lubricate the catheter with alcohol-based gel.

Correct answer: B

Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.

5. A client with preeclampsia and postpartum hemorrhage is being cared for by a nurse. The nurse should recognize that which of the following medications is contraindicated?

• A. Methylergonovine
• B. Misoprostol
• C. Dinoprostone
• D. Oxytocin

Correct answer: A

Rationale: The correct answer is A, Methylergonovine. Methylergonovine is contraindicated in clients with preeclampsia due to the risk of hypertension. Misoprostol (choice B), Dinoprostone (choice C), and Oxytocin (choice D) are appropriate medications for managing postpartum hemorrhage and are not contraindicated in clients with preeclampsia.

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