Nursing Elites

1. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?

• A. Leaving the lesion uncovered and placing the infant supine
• B. Covering the lesion with a sterile, saline-soaked gauze
• C. Applying lotion to the lesion to keep it moist
• D. Covering the lesion with a dry, sterile gauze

Correct answer: B

Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.

2. Which of the following is a priority assessment for a client receiving intravenous vancomycin?

• A. Respiratory rate
• B. Blood pressure
• C. Urine output
• D. Hearing acuity

Correct answer: D

Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.

3. The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

• A. The causes of major depression are unknown.
• B. Major affective disorders in parents increase depression in children.
• C. Boys are more likely than girls to be depressed.
• D. The prevalence rate is higher in prepubescent children.

Correct answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

4. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

• A. Capillary refill takes > 3 seconds.
• B. Episodes of vertigo and loss of balance.
• C. Average daily output of 1200 ml.
• D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

5. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?

• A. Neutralizes stomach acid
• B. Decreases gastric acid secretion
• C. Covers the ulcer site and protects it from acid
• D. Improves gastric motility

Correct answer: C

Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.

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