Nursing Elites

1. 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.

2. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Increased blood pressure
• C. Tachypnea
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.

3. A nurse is teaching a client about the use of duloxetine. Which of the following should be included?

• A. It is an antidepressant medication
• B. It can cause weight gain
• C. Monitor for liver function
• D. It has no side effects

Correct answer: C

Rationale: The correct answer is C: 'Monitor for liver function.' Duloxetine is an antidepressant medication, not an antipsychotic, so choice A is incorrect. One of the common side effects of duloxetine is weight gain, making choice B incorrect. Choice D, stating that duloxetine has no side effects, is inaccurate as all medications have the potential for side effects. Monitoring liver function is crucial with duloxetine because it can impact liver function, emphasizing the importance of regular checks to ensure the client's safety.

4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?

• A. Offer advice on coping strategies
• B. Encourage the partner to ask for help when needed
• C. Discuss the importance of grieving alone
• D. Suggest the partner avoid talking about the loss

Correct answer: B

Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.

5. A healthcare provider is assessing a client with congestive heart failure. Which of the following signs should the healthcare provider monitor?

• A. Peripheral edema
• B. Decreased appetite
• C. Fatigue
• D. All of the above

Correct answer: D

Rationale: Correct! In a client with congestive heart failure, peripheral edema, decreased appetite, and fatigue are important signs to monitor as they can indicate worsening heart failure. Peripheral edema is a common sign of fluid retention due to the heart's inability to pump effectively, decreased appetite may indicate worsening heart function, and fatigue can be a result of inadequate cardiac output. Monitoring all these signs is crucial for early intervention and management. Choices A, B, and C are incorrect because monitoring only one symptom may not provide a comprehensive assessment of the client's condition.

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