Nursing Elites

1. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?

• A. Contact provider if the cord turns black
• B. Clean the base of the cord with hydrogen peroxide daily
• C. Keep the cord dry until it falls off
• D. The cord stump will fall off in ten days

Correct answer: C

Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.

2. A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

• A. The TPN solution has an oily appearance and a layer of fat on top of the solution.
• B. The TPN solution contains added electrolytes, vitamins, and trace elements.
• C. The bag of TPN was prepared by the pharmacy 12 hours prior.
• D. The bag of TPN is labeled with the client's name, medical record number, and prescription.

Correct answer: A

Rationale: A TPN solution with an oily appearance and a layer of fat on top indicates that the solution is 'cracked' and should not be used as it may have separated or deteriorated. This finding suggests a need to obtain a new bag of TPN before administering. Options B, C, and D are normal aspects of TPN administration. Option B confirms the presence of essential components in the TPN solution, option C provides information about the preparation time, and option D ensures proper identification and matching of the TPN with the correct client.

3. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

• A. Notify the healthcare provider
• B. Recheck the client's BP
• C. Document the findings
• D. Administer antihypertensive medication

Correct answer: B

Rationale: The correct answer is to recheck the client's BP. It is essential for the nurse to verify the accuracy of the initial reading by reassessing the blood pressure. Notifying the healthcare provider or administering antihypertensive medication should only occur after confirming the elevated blood pressure through a recheck. Documenting the findings is important but should follow the confirmation of the BP reading.

4. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

• A. Ventrogluteal
• B. Deltoid
• C. Dorsogluteal
• D. Vastus lateralis

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

5. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?

• A. Keep a padded tongue depressor near the bedside
• B. Place a pillow under the client’s head while in bed during a seizure
• C. Administer diazepam intravenously at the onset of seizures
• D. Position the client on their side during a seizure

Correct answer: D

Rationale: Clients who have seizures are at risk for injury and aspiration. Therefore, the nurse should instruct the family to position the client on their side during a seizure to maintain a clear airway. Placing a padded tongue depressor near the bedside (Choice A) is not recommended, as it can lead to oral injury during a seizure. Placing a pillow under the client’s head (Choice B) can obstruct the airway and increase the risk of aspiration. Administering diazepam orally (Choice C) is not typically done by family members during a seizure; this is usually prescribed by healthcare providers for specific situations.

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