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. What is the appropriate action when a patient experiences an allergic reaction to a medication?

• A. Administer epinephrine
• B. Discontinue the medication
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.

3. A client who is at 10 weeks of gestation is being taught about nutrition during pregnancy. Which statement by the client indicates an understanding of the teaching?

• A. I should consume 1,200 calories per day.
• B. I should increase my daily intake of folic acid.
• C. I should drink 2 liters of water each day.
• D. I should limit my intake of iron-rich foods.

Correct answer: B

Rationale: The correct answer is B. Increasing folic acid intake is crucial during pregnancy to prevent neural tube defects. Option A is incorrect because calorie requirements during pregnancy vary and are generally higher than 1,200 calories per day. Option C is not specific to pregnancy nutrition teaching, although hydration is important. Option D is incorrect as iron-rich foods are typically recommended during pregnancy to prevent anemia.

4. How should a healthcare professional manage a patient with fluid overload in heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor intake and output
• D. Administer diuretics

Correct answer: A

Rationale: Monitoring daily weight is crucial in managing a patient with fluid overload in heart failure. Weight fluctuations can indicate fluid retention or loss, guiding healthcare professionals in adjusting treatment. While checking for edema (Choice B) and monitoring intake and output (Choice C) are important aspects of patient care, they are not as direct in assessing fluid overload as daily weight monitoring. Administering diuretics (Choice D) is a treatment option based on the assessment of fluid overload, making it a secondary intervention compared to monitoring weight.

5. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

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