Nursing Elites

1. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

• A. Provide an orthodontic pacifier for comfort
• B. Offer fluids using a straw
• C. Cleanse the suture line with a cotton-tip swab
• D. Remove elbow splints periodically to perform range of motion

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

2. A nurse is providing discharge instructions about breast engorgement to a client who has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction?

• A. I can wear a supportive bra
• B. I will apply cold compresses to my breasts
• C. I will manually express breast milk
• D. I can take a mild analgesic

Correct answer: C

Rationale: The correct answer is C. Manually expressing breast milk will stimulate more milk production, which contradicts the goal of reducing milk supply in clients who choose not to breastfeed. Choices A, B, and D are correct statements that can help relieve breast engorgement without promoting further milk production.

3. Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?

• A. Cold stress
• B. Hyperthermia
• C. Dehydration
• D. Hypoxia

Correct answer: A

Rationale: Placing the newborn under a radiant heat warmer is used to prevent cold stress. Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature, potentially resulting in hypoglycemia and metabolic acidosis if not addressed. The radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications. Choices B, C, and D are incorrect because the primary purpose of using a radiant warmer in this scenario is to prevent cold stress specifically, not hyperthermia, dehydration, or hypoxia.

4. A client has been prescribed metformin. What should be included in the teaching?

• A. It can cause weight gain
• B. Take it with food
• C. It is an insulin
• D. Monitor for hyperglycemia

Correct answer: B

Rationale: The correct answer is to take metformin with food. This is important to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect as metformin is not typically associated with weight gain. Choice C is wrong as metformin is not an insulin but a medication that helps control blood sugar levels. Choice D is also incorrect as metformin is not known to cause hyperglycemia.

5. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?

• A. Constipation
• B. Blurred vision
• C. Fever
• D. Dry mouth

Correct answer: C

Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management. Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.

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