Nursing Elites

1. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

• A. Vesicle
• B. Macule
• C. Papule
• D. Nodule

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

2. A nurse is assessing a client who is 12 hours post-surgery. The client has an indwelling urinary catheter, and the nurse notes a urinary output of 15 mL/hr. Which of the following interventions should the nurse implement first?

• A. Irrigate the catheter
• B. Assess the patency of the catheter
• C. Increase the IV fluid rate
• D. Notify the provider

Correct answer: B

Rationale: The nurse should first assess the patency of the catheter to ensure that the low output is not caused by a blockage. It is crucial to rule out any obstructions before considering other interventions. Irrigating the catheter without verifying patency may worsen the situation if there is a blockage. Increasing IV fluid rate may not address the underlying issue if the problem lies with the catheter. Notifying the provider should come after ensuring the catheter's patency.

3. A healthcare professional is preparing to administer a hepatitis B vaccine. Which of the following should the healthcare professional verify?

• A. Client's allergy to eggs
• B. Client's vaccination history
• C. Client's weight
• D. Client's blood pressure

Correct answer: B

Rationale: The correct answer is B: Client's vaccination history. Before administering the hepatitis B vaccine, it is essential to verify the client's vaccination history to ensure they are due for the vaccine. This helps in preventing unnecessary vaccinations and ensures the appropriate timing and dosage. Option A, the client's allergy to eggs, is not directly related to administering the hepatitis B vaccine. Option C, the client's weight, and option D, the client's blood pressure, are not factors that need to be specifically verified before administering the hepatitis B vaccine.

4. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?

• A. Blood glucose levels
• B. Serum potassium levels
• C. Liver function tests
• D. Heart rate

Correct answer: A

Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.

5. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

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