Nursing Elites

1. While caring for a newborn with jaundice receiving phototherapy, what action should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take while caring for a newborn with jaundice receiving phototherapy is to ensure that the newborn wears a diaper. This is essential to prevent skin irritation during phototherapy. Feeding the infant glucose water or applying lotion are not pertinent to managing jaundice or phototherapy. Keeping the infant's head covered with a cap is also not necessary for this specific situation.

2. A nurse is caring for a client who is at risk for developing deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

• A. Massage the client's legs every 4 hours.
• B. Administer prophylactic antibiotics.
• C. Apply sequential compression devices to the client's legs.
• D. Encourage the client to remain on bed rest.

Correct answer: C

Rationale: Applying sequential compression devices is the appropriate intervention for a client at risk for developing deep vein thrombosis (DVT). This intervention helps prevent venous stasis by promoting circulation in the lower extremities, reducing the risk of DVT. Massaging the client's legs every 4 hours is contraindicated as it can dislodge a blood clot and increase the risk of embolism. Administering prophylactic antibiotics is not indicated for preventing DVT. Encouraging the client to remain on bed rest can contribute to venous stasis and increase the risk of developing DVT.

3. A nurse in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

• A. Obtain a baseline ECG
• B. Obtain a blood specimen for ABG analysis
• C. Insert an 18-gauge IV catheter
• D. Administer 100% humidified oxygen

Correct answer: D

Rationale: In a client experiencing drooling and hoarseness following a burn injury, the priority action for the nurse is to administer 100% humidified oxygen. This is crucial to maintain the airway and address respiratory distress, which takes precedence over obtaining an ECG, collecting blood for ABG analysis, or inserting an IV catheter. Providing oxygen therapy is essential in ensuring the client's oxygenation and respiratory function are optimized in this emergency situation.

4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 150 mg/dL
• B. Serum sodium level of 138 mEq/L
• C. Serum potassium level of 3.0 mEq/L
• D. Serum albumin level of 3.8 g/dL

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.0 mEq/L is below the normal range and indicates hypokalemia, which should be reported to the provider. Hypokalemia can lead to serious complications such as cardiac arrhythmias. Choices A, B, and D are within normal ranges and do not require immediate reporting. A blood glucose level of 150 mg/dL is slightly elevated but not critically high. A serum sodium level of 138 mEq/L is within the normal range. A serum albumin level of 3.8 g/dL is also within the normal range.

5. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer oxygen
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

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