Nursing Elites

1. A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

• A. You should keep your baby's identification band on at all times.
• B. It is safe to leave your baby unattended in the room.
• C. Identification bands should be applied immediately after birth.
• D. Avoid public announcements about your baby's birth.

Correct answer: D

Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.

2. A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

• A. A client who was just given a glass of orange juice for a low blood glucose level.
• B. A client who is scheduled for a procedure in 1 hr.
• C. A client who has 100 mL of fluid remaining in his IV bag.
• D. A client who received a pain medication 30 min ago for postoperative pain.

Correct answer: A

Rationale: A client with low blood glucose levels needs immediate assessment to ensure stabilization. Hypoglycemia can lead to serious complications if not addressed promptly. The other options do not present immediate life-threatening situations that require urgent assessment. Option B can be attended to after addressing the client with low blood glucose levels. Option C can be managed based on the infusion rate and the client's condition. Option D, although important, can be assessed after ensuring the client with low blood glucose levels is stable.

3. A nurse is planning care for a client who is postoperative following a laminectomy. Which of the following interventions should the nurse include in the plan of care?

• A. Elevate the client's legs while in bed.
• B. Reposition the client every 2 hours.
• C. Maintain bed rest for the first 24 hours postoperatively.
• D. Ambulate the client on the first postoperative day.

Correct answer: D

Rationale: Ambulating the client on the first postoperative day is crucial to prevent complications like deep vein thrombosis and aid in the recovery process. Elevating the legs while in bed can help with circulation but is not as effective in preventing complications related to immobility post-surgery. Repositioning every 2 hours is important for preventing pressure ulcers but does not directly address postoperative care. Maintaining bed rest for the first 24 hours postoperatively can increase the risk of complications associated with immobility, making early ambulation a more appropriate intervention.

4. A nurse is caring for a client who has a prescription for spironolactone. Which of the following foods should the nurse recommend?

• A. Chicken breast
• B. Pasta
• C. Spinach
• D. Yogurt

Correct answer: A

Rationale: Correct Answer: Chicken breast. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Foods high in potassium, like spinach and yogurt, should be avoided when taking spironolactone to prevent hyperkalemia. Chicken breast, being a low-potassium protein source, is a suitable recommendation for clients on spironolactone therapy.

5. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

• A. Position the client on their left side.
• B. Insert the enema tubing 8 cm (3.1 in) into the client's rectum.
• C. Hold the container of the enema solution 61 cm (24 in) above the client.
• D. Advance the enema tubing 15 cm (6 in) into the client's rectum.

Correct answer: C

Rationale: The correct action the nurse should take when administering a cleansing enema is to hold the container of the enema solution 61 cm (24 in) above the client. This height facilitates the proper flow of the solution into the client's rectum. Positioning the client on their left side helps facilitate the administration process, but it is not the specific action related to the enema solution. Inserting the enema tubing 8 cm (3.1 in) into the rectum is incorrect as it may not deliver the solution effectively. Advancing the enema tubing 15 cm (6 in) into the client's rectum is excessive and could cause trauma.

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