Nursing Elites

1. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

2. The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?

• A. Order a chest X-ray
• B. Obtain a peripheral O2 saturation reading
• C. Obtain an order for complete blood count
• D. Tell the patient to stay in bed

Correct answer: B

Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.

3. Following-up Mrs. Luy, G5P4, you notice her eldest son is underweight and her youngest daughter looks thin and pale. Mrs. Luy's present pregnancy would mean another additional member of the family. This can be considered as:

• A. health deficit
• B. health deficit and health threat
• C. health threat
• D. foreseeable crisis

Correct answer: C

Rationale: The correct answer is C: 'health threat.' The new pregnancy poses a health threat due to the potential strain on resources and the existing issues with the children, such as underweight and being pale. Choice A is incorrect as it does not fully capture the potential risks associated with the new pregnancy. Choice B is also incorrect as it includes 'health deficit,' which is not explicitly mentioned in the scenario. Choice D, 'foreseeable crisis,' is not the most fitting description of the situation presented.

4. A client with chronic renal failure is receiving peritoneal dialysis. The nurse should assess the client for which of the following complications?

• A. Hypertension
• B. Hyperglycemia
• C. Hypokalemia
• D. Hypernatremia

Correct answer: B

Rationale: The correct answer is B: Hyperglycemia. In peritoneal dialysis, hyperglycemia can occur due to the glucose content of the dialysate solution. This high glucose concentration can lead to increased blood sugar levels in the client. Option A, Hypertension, is a common complication in chronic renal failure but is not directly related to peritoneal dialysis. Option C, Hypokalemia, is more commonly associated with loop diuretics or inadequate potassium intake. Option D, Hypernatremia, is more often seen in conditions of excessive sodium intake or water loss, rather than in peritoneal dialysis.

5. 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.

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