Nursing Elites

1. A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?

• A. Encourage the mother to breastfeed the newborn
• B. Gavage feed 60 mL (2 oz) of glucose water
• C. Administer 10 mL of D5W via IV
• D. Recheck the glucose level in 2 hours

Correct answer: A

Rationale: Encouraging the mother to breastfeed the newborn is the most appropriate action in this scenario. Breastfeeding can quickly raise blood glucose levels in newborns. A blood glucose level of 45 mg/dL is often acceptable in newborns, but close monitoring is necessary. Gavage feeding with glucose water or administering D5W via IV may not be necessary at this point and could lead to potential risks of overfeeding or hypoglycemia. Rechecking the glucose level in 2 hours may delay necessary intervention, as breastfeeding can promptly address the low blood glucose levels.

2. A nurse is reviewing psychosocial stages of development for a school-age child. What would be an expected behavioral finding for this child?

• A. Personalize values and beliefs and base reasoning on ethical fairness principles.
• B. Develop a sense of personal identity that is influenced by family expectations.
• C. Develop a sense of industry through advances in learning.
• D. Take on new experiences and when unable to accomplish tasks, may feel guilty.

Correct answer: C

Rationale: The correct answer is C. School-age children (6-12 years) are in Erikson's stage of industry vs. inferiority. During this stage, they strive to develop a sense of industry through learning and socialization. They seek to excel in various areas, such as schoolwork or activities, and look for approval from peers and adults. Choices A, B, and D are incorrect because personalizing values and beliefs, developing personal identity influenced by family expectations, and feeling guilty for inability to accomplish tasks are not typical behavioral findings for a school-age child in the context of psychosocial development.

3. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

• A. Maintain an eye mask over the newborn's eyes
• B. Feed the newborn every hour
• C. Monitor the newborn's temperature
• D. Administer vitamin K

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

4. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?

• A. Take the medication with food
• B. Take the medication at bedtime
• C. Stand up slowly to prevent dizziness
• D. Increase fluid intake

Correct answer: C

Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.

5. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

• A. Serum sodium 138 mEq/L
• B. Urine specific gravity 1.001
• C. Serum calcium 10 mg/dL
• D. Urine pH 6

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.

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