Nursing Elites

1. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

• A. Check the newborn's temperature every 4 hours
• B. Apply moisturizing lotion to the newborn's skin every 4 hours
• C. Give the newborn 1 oz of glucose water every 4 hours
• D. Reposition the newborn every 2 to 3 hours

Correct answer: D

Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin. Checking the newborn's temperature is important, but it should be done more frequently, such as every 4 hours, to monitor for any signs of overheating or hypothermia. Applying moisturizing lotion is not indicated during phototherapy as it may interfere with the treatment. Giving glucose water is not necessary for the management of hyperbilirubinemia.

2. A client is being educated about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching?

• A. I will need to have the IUD replaced each year.
• B. I will need to apply a spermicide prior to intercourse.
• C. I should expect my periods to stop while I have the IUD.
• D. I should check for the string each month after menstruation.

Correct answer: D

Rationale: The correct answer is D because the client should check for the string each month after menstruation to ensure the IUD is in place. This practice helps in identifying any displacement of the IUD. Choices A, B, and C are incorrect. A is incorrect because IUDs have different durations depending on the type, not all require yearly replacement. B is incorrect because IUDs do not require spermicide for effectiveness. C is incorrect because while some individuals may experience changes in their menstrual patterns, it is not guaranteed that periods will stop while using an IUD.

3. A client scheduled for an electroencephalogram (EEG) is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should not wash my hair before the procedure.”
• B. “I will be given a sedative 1 hour before the procedure.”
• C. “I should refrain from eating before the procedure.”
• D. “I will be exposed to flashes of light during the procedure.”

Correct answer: D

Rationale: The correct answer is D. During an electroencephalogram (EEG), flashes of light or patterns are often used to stimulate the brain and provoke responses, helping to assess brain activity and the potential for seizures. Choices A, B, and C are incorrect because washing the hair, receiving a sedative, and refraining from eating are not usually related to EEG procedures and do not reflect understanding of the teaching provided by the nurse.

4. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

5. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?

• A. PT and INR
• B. Blood glucose levels
• C. Complete blood count (CBC)
• D. Platelet count

Correct answer: A

Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.

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