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. What is the primary focus of postoperative nursing care for the client with colon trauma?

• A. Monitoring for elevated coagulation studies
• B. Observation for and prevention of fistulas
• C. Monitoring for signs of hyponatremia
• D. Observation for and prevention of infection

Correct answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

3. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?

• A. Administer the infusion via an infusion pump
• B. Obtain the current serum potassium level
• C. Continuously monitor blood pressure
• D. Teach guided imagery to decrease pain

Correct answer: C

Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.

4. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

5. The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?

• A. Case management and screening for clients with HIV.
• B. Regional relocation center for earthquake victims.
• C. Vitamin supplements for high-risk pregnant women.
• D. Lead screening for children in low-income housing.

Correct answer: C

Rationale: The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.

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