Nursing Elites

1. A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Hypertonia
• B. Jitteriness
• C. Acrocyanosis
• D. Generalized petechiae

Correct answer: B

Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy. Choice A, Hypertonia, is not typically associated with hypoglycemia but rather with conditions like hypocalcemia. Acrocyanosis (Choice C) is a benign condition characterized by peripheral cyanosis and is not directly linked to hypoglycemia. Generalized petechiae (Choice D) are tiny red or purple spots on the skin due to bleeding and are not specific to hypoglycemia.

2. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?

• A. Glaucoma
• B. Hypertension
• C. Polycythemia
• D. Migraine headaches

Correct answer: A

Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.

3. A client scheduled for an electroencephalogram (EEG) is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should not wash my hair before the procedure.”
• B. “I will be given a sedative 1 hour before the procedure.”
• C. “I should refrain from eating before the procedure.”
• D. “I will be exposed to flashes of light during the procedure.”

Correct answer: D

Rationale: The correct answer is D. During an electroencephalogram (EEG), flashes of light or patterns are often used to stimulate the brain and provoke responses, helping to assess brain activity and the potential for seizures. Choices A, B, and C are incorrect because washing the hair, receiving a sedative, and refraining from eating are not usually related to EEG procedures and do not reflect understanding of the teaching provided by the nurse.

4. A healthcare provider is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the healthcare provider take?

• A. Use basic gloves and a mask.
• B. Choose the highest level of protection equipment available.
• C. Use only respiratory protection.
• D. Ask a colleague for advice.

Correct answer: B

Rationale: In situations where the type of hazard is unknown, the healthcare provider should choose the highest level of protection equipment available. This helps ensure adequate protection against any potential hazards that may be present. Using only basic gloves and a mask (Choice A) may not provide sufficient protection if the hazard is more severe. Opting for respiratory protection only (Choice C) may leave other areas of the body vulnerable to exposure. While asking a colleague for advice (Choice D) is good practice in general, in urgent situations like mass-casualty incidents with unknown hazards, it is crucial to prioritize immediate protection by selecting the highest level of PPE.

5. A client who is 2 hours postpartum reports heavy bleeding and passing large clots. What is the nurse's priority action?

• A. Perform fundal massage
• B. Administer oxytocin IV
• C. Check vital signs
• D. Encourage the client to void

Correct answer: A

Rationale: The correct answer is A: Perform fundal massage. Fundal massage promotes uterine contractions, which is the initial action to reduce postpartum hemorrhage caused by uterine atony. Checking vital signs (choice C) is important but not the priority when active bleeding is present. Administering oxytocin IV (choice B) may be needed but is not the priority action. Encouraging the client to void (choice D) does not address the underlying issue of postpartum hemorrhage and should not be the priority.

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