Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid crowded places to reduce my risk of infection.
• B. I will take this medication on an empty stomach.
• C. I will stop taking this medication if I experience nausea.
• D. I will take this medication for 2 weeks and then stop.

Correct answer: A

Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.

2. A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?

• A. Loose stools.
• B. Jitteriness.
• C. Hypertonia.
• D. Abdominal distention.

Correct answer: B

Rationale: Corrected Rationale: Jitteriness is a common manifestation of hypoglycemia in newborns. Choice A, 'Loose stools,' is not typically associated with hypoglycemia in newborns. Choice C, 'Hypertonia,' is not a common manifestation of hypoglycemia in newborns; instead, hypotonia may be observed. Choice D, 'Abdominal distention,' is not a typical manifestation of hypoglycemia in newborns.

3. A nurse is assessing a client who is 48 hours postoperative following a hip replacement. Which of the following findings should the nurse report to the provider?

• A. Heart rate 90/min.
• B. WBC count 15,000/mm3.
• C. Urinary output 75 mL in the past 4 hours.
• D. Temperature 37.8°C (100°F).

Correct answer: B

Rationale: An elevated WBC count 48 hours postoperatively may indicate an infection and should be reported to the provider. Choice A, a heart rate of 90/min, is within normal limits and not a concerning finding postoperatively. Choice C, urinary output of 75 mL in the past 4 hours, may indicate decreased renal perfusion, but an elevated WBC count is a more urgent finding. Choice D, a temperature of 37.8°C (100°F), which is slightly elevated, could be indicative of the body's normal response to surgery and is not as alarming as an elevated WBC count.

4. A nurse is caring for a client who has deep vein thrombosis. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client's fluid intake to 1500 mL per day.
• B. Avoid massaging the affected extremity to relieve pain.
• C. Do not apply cold packs to the client's affected extremity.
• D. Elevate the client's affected extremity when in bed.

Correct answer: D

Rationale: The correct answer is to elevate the client's affected extremity when in bed. Elevating the extremity helps to reduce swelling and improve venous return in clients with DVT. Limiting fluid intake to 1500 mL per day (Choice A) is not directly related to managing DVT. Massaging the affected extremity (Choice B) can dislodge a clot and lead to serious complications. Applying cold packs (Choice C) can vasoconstrict blood vessels, potentially worsening the condition by reducing blood flow.

5. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Auscultate the newborn's apical pulse for 60 seconds
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence

Correct answer: C

Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.

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