Nursing Elites

1. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

2. A nurse is caring for a patient whose family member requests to view the patient’s medical record. What response should the nurse make?

• A. “The patient should provide permission to share the records with you.”
• B. “You can view the records if the provider approves it.”
• C. “I will allow you to see the chart if the patient is unable to give consent.”
• D. “You need to fill out a request form.”

Correct answer: A

Rationale: In this scenario, the nurse should respond by indicating that the patient needs to provide permission to share their medical records with the family member. Patient confidentiality is a fundamental principle in healthcare, and sharing medical records without the patient's consent is a violation of privacy. Choice B is incorrect because the provider's approval alone is not sufficient to share medical records, as patient consent is crucial. Choice C is incorrect because viewing the patient's chart without the patient's consent is not appropriate. Choice D is incorrect as filling out a request form does not address the issue of patient consent, which is essential for sharing medical information.

3. A healthcare professional is preparing to administer a hepatitis B vaccine. Which of the following should the healthcare professional verify?

• A. Client's allergy to eggs
• B. Client's vaccination history
• C. Client's weight
• D. Client's blood pressure

Correct answer: B

Rationale: The correct answer is B: Client's vaccination history. Before administering the hepatitis B vaccine, it is essential to verify the client's vaccination history to ensure they are due for the vaccine. This helps in preventing unnecessary vaccinations and ensures the appropriate timing and dosage. Option A, the client's allergy to eggs, is not directly related to administering the hepatitis B vaccine. Option C, the client's weight, and option D, the client's blood pressure, are not factors that need to be specifically verified before administering the hepatitis B vaccine.

4. A client is prescribed digoxin and has a potassium level of 3.0 mEq/L. Which of the following actions should the nurse take?

• A. Administer digoxin without any modifications
• B. Administer the medication at a lower dose
• C. Monitor serum potassium levels
• D. Discontinue the medication if potassium levels rise

Correct answer: A

Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia, which increases the risk of digoxin toxicity. In this case, the nurse should administer the digoxin without any modifications. Lowering the dose (Choice B) may not be necessary if the potassium level is not critically low. Monitoring serum potassium levels (Choice C) is important but should not delay the administration of digoxin. Discontinuing the medication (Choice D) is not the initial action to take unless the potassium levels become severely low and life-threatening.

5. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

• A. Place several pillows behind the client’s head
• B. Place the client in a Sims' position
• C. Keep the client’s neck in a midline position
• D. Maintain flexion of the client’s hips at a 90° angle

Correct answer: C

Rationale: Keeping the client’s neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client’s head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.

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