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. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Which intervention is most helpful in assisting the client to hear the nurse’s question?

• A. Move to the client's other side.
• B. Speak louder into the client's ear with the hearing aid.
• C. Ask the client to adjust the hearing aid volume.
• D. Restate questions articulating consonants carefully.

Correct answer: D

Rationale: Restating questions with clear articulation is the most helpful intervention in assisting the client to hear the nurse's question. This approach ensures that the client can better understand the question, especially if there are issues with the hearing aid. Moving to the client's other side or speaking louder into the ear with the hearing aid may not effectively address the problem of clarity in communication. Asking the client to adjust the hearing aid volume assumes that the issue lies solely with the volume, while restating questions with clear articulation can help overcome various hearing difficulties.

3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?

• A. Increased respiratory rate
• B. Decreased level of consciousness
• C. Improved oxygen saturation
• D. Complaints of dry mouth

Correct answer: B

Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.

4. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?

• A. Mild soap and water
• B. A cotton ball
• C. Mineral oil
• D. Alcohol swabs

Correct answer: C

Rationale: To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (Choice A) may not be effective in completely removing zinc oxide. A cotton ball (Choice B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (Choice D) can be harsh on the skin and are not recommended for this purpose.

5. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

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