Nursing Elites

1. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

• A. Proceed with the dressing change
• B. Restart the procedure if the sterile solution splashes onto the sterile field
• C. Continue without concern for minor splashes
• D. Delegate the task to another nurse

Correct answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

2. 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.

3. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?

• A. Increase potassium-rich foods
• B. Limit sodium intake
• C. Avoid potassium supplements
• D. Increase protein intake

Correct answer: C

Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.

4. A healthcare professional is assessing a client for signs of anemia. Which of the following findings should the healthcare professional expect?

• A. Increased energy levels
• B. Pale skin
• C. Elevated blood pressure
• D. Decreased heart rate

Correct answer: B

Rationale: Pale skin is a common sign of anemia due to reduced hemoglobin levels, leading to decreased oxygen delivery to tissues. This results in skin pallor. Choices A, C, and D are incorrect. Anemia typically causes fatigue and decreased energy levels (not increased), low blood pressure (not elevated), and tachycardia (increased heart rate) to compensate for the decreased oxygen-carrying capacity of the blood.

5. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Fatigue
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.

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