Nursing Elites

1. A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first?

• A. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg
• B. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap
• C. Measure and record the infant's frontal-occipital circumference
• D. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis

Correct answer: B

Rationale: The correct first action for a newborn potentially exposed to HIV is to bathe the infant with dilute chlorhexidine or soap. This helps reduce the risk of infection. Initiating treatment with zidovudine would be important but not the first priority. Measuring and recording the infant's frontal-occipital circumference and administering vitamin K are important tasks but are not the priority when dealing with potential HIV exposure. Immediate hygiene measures are crucial to minimize the risk of transmission.

2. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?

• A. Describe feelings about taking daily medications
• B. Take medications in the presence of the nurse
• C. Notify the nurse after self-medication is completed
• D. Keep a daily record of all medications taken

Correct answer: B

Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.

3. Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?

• A. Describes a schedule for antacid use in combination with other prescribed medications
• B. Selects a pattern of small meals interspersed with fluid intake
• C. Commits to engaging in a variety of stress reduction techniques
• D. Expresses a commitment to decrease nicotine intake

Correct answer: B

Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.

4. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?

• A. From the peak of one contraction to the peak of the next contraction
• B. From the beginning of one contraction to the end of that contraction
• C. From the beginning of one contraction to the beginning of the next contraction
• D. From the end of one contraction to the beginning of the next contraction

Correct answer: C

Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.

5. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?

• A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
• B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
• C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
• D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.

Correct answer: C

Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.

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