Nursing Elites

1. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?

• A. Apply cold compresses to both breasts for comfort.
• B. Instruct the client to run warm water on her breasts.
• C. Wear a loose-fitting bra to prevent nipple irritation.
• D. Express small amounts of milk to relieve pressure.

Correct answer: A

Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.

2. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?

• A. Administer prescribed IV solution.
• B. Give oral rehydration solution.
• C. Encourage small, frequent meals.
• D. Offer ginger tea to reduce nausea.

Correct answer: A

Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.

3. Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child’s plan of care?

• A. Monitor serum glucose for adjustment in the infusion rate of regular insulin (Novolin R).
• B. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N).
• C. Demonstrate to the parents how to program an insulin pen for daily glucose regulation.
• D. Consult with the healthcare provider about the use of insulin detemir (Levemir Flex Pen).

Correct answer: A

Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA. Choice B is incorrect as it focuses on a different type of insulin and compliance schedule without addressing the immediate needs of managing DKA. Choice C is not the priority action and involves educating parents on a different method of insulin administration. Choice D is also not the most important action as it suggests consulting with the healthcare provider about a different type of insulin rather than focusing on immediate glucose monitoring for insulin adjustment in DKA management.

4. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?

• A. Muscle tension decreases with fine motor skill projects, so these activities should be encouraged.
• B. The chorea or movements are temporary and will eventually disappear.
• C. Permanent lifestyle changes are not needed to promote safety in the home.
• D. Consistent discipline is not directly related to controlling the movements.

Correct answer: B

Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course. Choices A, C, and D are incorrect because muscle tension, permanent lifestyle changes, and consistent discipline are not directly related to the resolution of chorea in rheumatic fever.

5. A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?

• A. Administer oral acyclovir.
• B. Apply calamine lotion to soothe itching.
• C. Encourage scratching to relieve itching.
• D. Encourage bed rest to avoid spreading the rash.

Correct answer: B

Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.

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