Nursing Elites

1. When is the first dose of Hepatitis B vaccine typically administered?

• A. In the hospital at birth
• B. At one year old
• C. At six months
• D. At 18 months

Correct answer: A

Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. This early administration is crucial in establishing immunity in infants, as delaying the vaccine increases the risk of infection. Options B, C, and D are incorrect because delaying the administration of the Hepatitis B vaccine can leave infants vulnerable to the virus during the critical early months of life when they are most susceptible.

2. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.

3. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

• A. Check the bath water temperature.
• B. Shut the bathroom door.
• C. Ensure that the client has voided.
• D. Provide extra towels.

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

4. Which action should the nurse implement when using the confrontation technique during a vision exam?

• A. Use an ophthalmoscope to observe the client's pupil constriction when a strong light is shone on it.
• B. Stand behind the client and direct the client to report when an object enters the peripheral field of vision.
• C. Display a series of four cards with printing of varying sizes to the client and ask which card the client sees most clearly.
• D. Sit facing the client, look directly at the client's face, and move an object inward from the periphery.

Correct answer: D

Rationale: During a vision exam, the confrontation technique is used to assess peripheral vision. By sitting facing the client and moving an object inward from the periphery while looking directly at the client's face, the nurse allows the client to indicate when the object enters the visual field. This method helps in determining the extent of the client's peripheral vision accurately. Choices A, B, and C are incorrect as they do not describe the appropriate method for using the confrontation technique during a vision exam. Choice A involves using an ophthalmoscope to observe pupil constriction, choice B involves testing the peripheral field of vision without the confrontation technique, and choice C describes the Snellen eye chart test for visual acuity, which is not related to the confrontation technique.

5. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. The client's weight increases by 1 kg in 24 hours.
• B. The client's peritoneal effluent is cloudy.
• C. The client's blood pressure is 140/90 mm Hg.
• D. The client's peritoneal effluent is clear and pale yellow.

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

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