Nursing Elites

1. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take the medication with milk
• B. Take with a glass of orange juice
• C. Take at bedtime
• D. Take with meals

Correct answer: B

Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.

2. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

• A. The dressing was changed 7 days ago
• B. The circumference of the client’s upper arm has increased by 10%
• C. The catheter has not been used in 8 hours
• D. The catheter has been flushed with 10 mL of sterile saline after medication use

Correct answer: B

Rationale: The correct answer is B. The circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion and then again during assessments. An increase in circumference could indicate deep vein thrombosis, which could be life-threatening. Choice A is not a concern as changing the dressing 7 days ago is within the recommended timeframe. Choice C is not alarming as the catheter not being used for 8 hours does not necessarily indicate a problem. Choice D indicates proper catheter care by flushing it with sterile saline after medication use, so it does not require provider notification.

3. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

4. A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

• A. WBC 3,000/mm3
• B. Hemoglobin 14 g/dL
• C. Platelets 250,000/mm3
• D. aPTT 30 seconds

Correct answer: A

Rationale: A WBC count of 3,000/mm3 indicates neutropenia, a dangerous complication of chemotherapy that increases the risk of infection and requires immediate attention. Neutropenia is a common side effect of chemotherapy and can lead to life-threatening infections. Reporting a low WBC count is crucial to ensure timely intervention. Choices B, C, and D are within normal ranges and do not pose immediate risks to the client undergoing chemotherapy.

5. A nurse is providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?

• A. This medication can cause your urine to turn a reddish-orange color.
• B. You should expect to take this medication for at least 6 months.
• C. You should avoid eating dairy products while on this medication.
• D. This medication can cause sensitivity to sunlight.

Correct answer: A

Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.

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