Nursing Elites

1. The mother of a 2-day-old infant girl expresses concern about a 'flea bite' type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer?

• A. We need to monitor the rash for signs of worsening or fever
• B. Your baby may have an allergic reaction to laundry detergent
• C. This is a common newborn rash that will resolve after several days
• D. This is likely a bacterial infection requiring antibiotics

Correct answer: C

Rationale: The rash described is typical of erythema toxicum neonatorum, a common and benign newborn rash that resolves on its own within a few days. No treatment is necessary, and the nurse should reassure the mother. Choice A is incorrect as the rash is self-limiting and does not require monitoring for worsening signs or fever. Choice B is incorrect as erythema toxicum neonatorum is not caused by an allergic reaction to laundry detergent. Choice D is incorrect as this rash is not indicative of a bacterial infection that requires antibiotics.

2. A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care?

• A. Social isolation related to hearing loss
• B. Risk for injury related to vertigo
• C. Impaired verbal communication
• D. Impaired hearing related to ear disease

Correct answer: B

Rationale: Vertigo is the primary symptom of Meniere's disease and can lead to falls and other injuries. Ensuring safety and addressing the risk of injury is the nurse's top priority. While social isolation and impaired hearing are significant concerns associated with Meniere's disease, the immediate danger of falls due to vertigo takes precedence in the plan of care. Impaired verbal communication, although important, is not as urgent as preventing injuries caused by vertigo.

3. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

4. A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?

• A. Assess the child's level of consciousness.
• B. Prepare to administer activated charcoal.
• C. Notify the poison control center.
• D. Obtain an order for serum acetaminophen levels.

Correct answer: D

Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.

5. A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?

• A. Monitor the client's urinary output hourly.
• B. Apply cool, moist dressings to the burned areas.
• C. Administer pain medication to reduce discomfort.
• D. Administer IV fluids to prevent hypovolemia.

Correct answer: A

Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.

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