Nursing Elites

1. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse include?

• A. The cord stump will fall off in 5 days.
• B. Contact the provider if the cord stump turns black.
• C. Clean the base of the cord with hydrogen peroxide daily.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct instruction for cord care is to keep the cord stump dry until it falls off. This helps prevent infection and promotes healing. Choice A is incorrect because the timing of when the cord stump falls off can vary, usually between 1-3 weeks. Choice B is incorrect as a black cord stump can be a normal part of the healing process, so it is unnecessary to contact the provider for this reason. Choice C is incorrect because cleaning the cord with hydrogen peroxide daily is not recommended as it can delay healing and cause irritation.

2. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 2 minutes with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase the oxytocin infusion.
• B. Maintain the oxytocin infusion.
• C. Discontinue the oxytocin infusion.
• D. Provide reassurance to the client.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. With contractions occurring every 2 minutes and lasting 90 seconds, this pattern indicates hyperstimulation, which can be harmful to the fetus. Discontinuing the oxytocin infusion is essential to prevent further harm. Increasing the oxytocin infusion would exacerbate the situation, maintaining it would continue the risk, and providing reassurance to the client, although important, does not address the need for immediate action to ensure the safety of the fetus.

3. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?

• A. Store unopened vials of insulin in the refrigerator, not the freezer.
• B. Rotate injection sites within the same region to prevent tissue damage.
• C. Administer insulin at a 90-degree angle for subcutaneous injections.
• D. Avoid massaging the injection site after administering insulin.

Correct answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.

4. A client is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Measure the client's blood glucose level every 6 hours
• B. Change the TPN tubing every 24 hours
• C. Weigh the client weekly
• D. Administer the TPN through a peripheral IV line

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client receiving total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. This practice helps reduce the risk of infection in clients receiving parenteral nutrition. Measuring the client's blood glucose level every 6 hours is important for clients on insulin therapy or with diabetes, but it is not directly related to TPN administration. Weighing the client weekly is essential for monitoring fluid status and nutritional progress, but it is not specific to TPN care. Administering TPN through a peripheral IV line is incorrect because TPN solutions are hypertonic and can cause phlebitis or thrombosis if administered through a peripheral line; a central venous access is typically used for TPN administration.

5. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

• A. Insert a tongue depressor into the client's mouth.
• B. Restrain the client's arms and legs.
• C. Turn the client onto their side.
• D. Place the client in a prone position.

Correct answer: C

Rationale: During a tonic-clonic seizure, the nurse should turn the client onto their side. This action helps maintain an open airway by allowing saliva or any vomitus to drain out of the mouth, reducing the risk of aspiration. Inserting a tongue depressor (choice A) is incorrect as it can cause injury to the client's mouth and is not recommended during a seizure. Restraining the client's arms and legs (choice B) can lead to physical harm and should be avoided. Placing the client in a prone position (choice D) is dangerous as it can obstruct the airway and hinder breathing, which is not suitable for a client experiencing a seizure.

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