Nursing Elites

1. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

2. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?

• A. Provide teaching to the parents
• B. Report suspected abuse to the appropriate agency
• C. Document the injuries and monitor the child
• D. Counsel the parents privately

Correct answer: B

Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.

3. A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Elevated blood pressure.
• C. Furrows in the tongue.
• D. Polyuria.

Correct answer: C

Rationale: The correct answer is C: 'Furrows in the tongue.' Dehydration commonly presents with furrows in the tongue due to decreased oral moisture. This physical finding indicates dehydration as the tongue loses moisture and becomes dry. Choice A, 'Bradycardia,' is not typically associated with dehydration; instead, tachycardia may be present as a compensatory mechanism. Elevated blood pressure, as mentioned in choice B, is not a typical finding in dehydration; in fact, dehydration often leads to a decrease in blood pressure. Polyuria, as in choice D, is more commonly associated with conditions like diabetes mellitus or diabetes insipidus, rather than dehydration.

4. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

5. What is the recommended intervention for a patient experiencing severe hypoglycemia?

• A. Administer glucagon
• B. Provide a source of glucose
• C. Monitor blood sugar
• D. Assess vital signs

Correct answer: A

Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.

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