Nursing Elites

1. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?

• A. Heel stick
• B. Respirations
• C. Heart rate
• D. Temperature

Correct answer: D

Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.

2. After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client’s plan of care?

• A. Ineffective coping
• B. Spiritual distress
• C. Acute pain
• D. Complicated grieving

Correct answer: B

Rationale: The client’s expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress. Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.

3. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?

• A. Current lab report indicates an Aptt at 1.5 times the client's control
• B. The client states that his right calf is aching and wants pain medication
• C. The spouse is assisting the client who is shaving with an electric razor
• D. Several bruised areas are noted on the client's upper extremities bilaterally

Correct answer: D

Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.

4. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct infusion rate can be calculated based on the information provided in the chart. With contractions occurring every 2-3 minutes, the recommended infusion rate is 5 ml/hr. This rate ensures proper hydration and medication delivery to support the client during labor. Choices B, C, and D are incorrect as they do not align with the calculated rate based on the contractions frequency and the client's needs.

5. After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol’s effectiveness?

• A. Compare the number of falls that occurred before and after protocol implementation
• B. Analyze data that reflects the unit’s costs incurred due to the new protocol
• C. Conduct a chart review on the unit to determine the number of clients at risk for falling
• D. Consult with the physical therapist to evaluate the benefits of the new fall protocol

Correct answer: A

Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.

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