Nursing Elites

1. What is the FIRST STEP for thermal protection of a newborn?

• A. Drying the baby thoroughly immediately after birth
• B. Covering the baby with a clean, dry cloth after the cord has been cut
• C. Drying the baby thoroughly after the cord has been cut
• D. Covering the baby with a clean, dry cloth immediately after birth

Correct answer: A

Rationale: The correct first step for thermal protection of a newborn is to dry the baby thoroughly immediately after birth. This helps prevent heat loss and is crucial in maintaining the baby's body temperature. Choice B, covering the baby with a clean, dry cloth after the cord has been cut, is not the initial step as drying the baby comes first. Choice C, drying the baby thoroughly after the cord has been cut, is also not the first step. Choice D, covering the baby with a clean, dry cloth immediately after birth, is not as effective as drying the baby to prevent heat loss.

2. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

• A. Suggest 3 to 4 warm sitz baths per day
• B. Cleanse the genitalia twice a day with soap and water
• C. Spray warm water over genitalia after urination
• D. Apply heat or cold to lesions as desired

Correct answer: A

Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.

3. A client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of digoxin toxicity?

• A. Tachycardia
• B. Hypotension
• C. Bradycardia
• D. Hyperglycemia

Correct answer: C

Rationale: The correct answer is C: Bradycardia. Digoxin toxicity often presents with bradycardia, which is a common sign of toxicity associated with this medication. Tachycardia (Choice A) is not typically seen with digoxin toxicity. Hypotension (Choice B) can occur but is less specific to digoxin toxicity. Hyperglycemia (Choice D) is not a typical sign of digoxin toxicity. Therefore, monitoring for bradycardia is crucial in clients receiving digoxin to detect toxicity early.

4. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?

• A. Hepatitis C (HepC)
• B. Influenza type B (HIB)
• C. Measles, mumps, rubella (MMR)
• D. Diphtheria, tetanus, pertussis (DTaP)

Correct answer: C

Rationale: The correct answer is C: Measles, mumps, rubella (MMR). MMR vaccine is commonly included in precollege physicals to ensure students are protected against these diseases. Choice A, Hepatitis C (HepC), is incorrect as the standard vaccine for hepatitis given in childhood is Hepatitis B. Choice B, Influenza type B (HIB), is not typically administered during precollege physicals but is recommended for younger children. Choice D, Diphtheria, tetanus, pertussis (DTaP), is usually given in early childhood and not typically repeated during precollege physicals.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?

• A. Decreased anteroposterior diameter
• B. Hyperresonance on percussion
• C. Increased breath sounds
• D. Prolonged expiratory phase

Correct answer: D

Rationale: The correct answer is D: Prolonged expiratory phase. In COPD, there is airflow obstruction leading to difficulty in exhaling air. This results in a prolonged expiratory phase. Choices A, B, and C are incorrect. Decreased anteroposterior diameter is associated with conditions like barrel chest in emphysema, not COPD. Hyperresonance on percussion is typical in conditions like emphysema, not necessarily in COPD. Increased breath sounds are not a typical finding in COPD; instead, diminished breath sounds may be present due to air trapping.

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