Nursing Elites

1. The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

• A. Take the client to the dining room with 1:1 supervision
• B. Inform the client they may go to the dining room when they control their behavior
• C. Hold the meal until the client is able to come out of seclusion
• D. Serve the meal to the client in the seclusion room

Correct answer: D

Rationale: In the scenario described, the manic client is in the seclusion room, and it is most appropriate for the nurse to serve the meal to the client in the seclusion room. This action helps maintain the client's nutritional needs while managing their behavior. Taking the client to the dining room with 1:1 supervision (Choice A) may pose safety risks both for the client and others. Informing the client they may go to the dining room when they control their behavior (Choice B) may not be feasible in a manic state. Holding the meal until the client is able to come out of seclusion (Choice C) can lead to nutritional deficiencies and does not address the immediate need for nutrition during the episode of mania.

2. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching?

• A. Clean the base of the cord with hydrogen peroxide daily.
• B. The cord stump will fall off in 5 days.
• C. Contact the provider if the cord stump turns black.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct answer is to keep the cord stump dry until it falls off. This is important to promote natural healing and prevent infection. Choice A is incorrect because cleaning the cord with hydrogen peroxide daily can actually delay healing and increase the risk of infection. Choice B is incorrect as the cord stump typically falls off within 1 to 3 weeks, not in 5 days. Choice C is incorrect because a cord stump turning black is a normal part of the healing process and does not necessarily indicate a problem requiring immediate provider contact.

3. A nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

• A. Administer scheduled doses of acetaminophen every 6 hr.
• B. Monitor the child's cardiac status.
• C. Administer antibiotics via intermittent IV bolus for 24 hr.
• D. Provide stimulation with children of the same age in the playroom.

Correct answer: B

Rationale: Monitoring cardiac status is crucial during the acute phase of Kawasaki disease because of the potential for coronary artery complications. Acetaminophen may be used for fever management but is not the priority intervention. Antibiotics are not indicated as Kawasaki disease is not caused by a bacterial infection. Providing stimulation in the playroom is important for the child's emotional well-being but does not address the immediate physiological concern of cardiac monitoring.

4. A client undergoing bariatric surgery is being taught about postoperative dietary changes by a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will drink carbonated beverages after surgery
• B. I will eat large meals after surgery
• C. I will avoid consuming solid foods for several weeks
• D. I will avoid taking small sips of liquids

Correct answer: C

Rationale: The correct answer is C because avoiding solid foods after bariatric surgery is crucial to prevent complications and promote healing. Choice A is incorrect as carbonated beverages can cause discomfort and should be avoided. Choice B is incorrect as large meals are not suitable after bariatric surgery. Choice D is incorrect as taking small sips of liquids is encouraged to prevent dehydration and promote recovery.

5. A nurse is reviewing the medical record of a client who is taking furosemide. Which of the following findings should the nurse report to the provider?

• A. Potassium level of 3.8 mEq/L
• B. Sodium level of 135 mEq/L
• C. Magnesium level of 1.6 mEq/L
• D. Calcium level of 8.5 mg/dL

Correct answer: C

Rationale: The correct answer is C. A magnesium level of 1.6 mEq/L is within the normal range, but monitoring potassium levels is crucial for clients taking furosemide. Furosemide can cause hypokalemia (low potassium levels), which can lead to adverse effects such as cardiac dysrhythmias. Sodium and calcium levels are not typically affected by furosemide, so they are not the priority findings to report to the provider in this case.

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