Nursing Elites

1. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

2. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.

• A. Hepatotoxicity
• B. Constipation
• C. Infusion reaction
• D. Immunosuppression

Correct answer: C

Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.

3. A nurse is reviewing dietary assessment findings for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?

• A. Leavened bread may be eaten during Passover
• B. Shellfish is commonly consumed in the diet
• C. Meat and dairy products are eaten separately
• D. Fasting from meat occurs during Hanukkah

Correct answer: C

Rationale: The correct answer is C. According to kosher dietary laws, meat and dairy products cannot be consumed together. This practice stems from the prohibition in Jewish law against cooking a young animal in its mother's milk. Therefore, the nurse should expect to find that meat and dairy products are eaten separately. Choices A, B, and D are incorrect. Leavened bread is not eaten during Passover (Choice A), shellfish is not consumed in the kosher diet (Choice B), and fasting from meat does not occur during Hanukkah (Choice D).

4. A client with lactose intolerance, who has eliminated dairy products from the diet, should increase consumption of which of the following foods?

• A. Spinach
• B. Peanut butter
• C. Ground beef
• D. Carrots

Correct answer: A

Rationale: Spinach is the correct answer because it is a good source of calcium, which is important for clients with lactose intolerance who are not consuming dairy products. Peanut butter, ground beef, and carrots do not provide as much calcium as spinach and are not the best choices for meeting the calcium needs of clients with lactose intolerance.

5. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?

• A. Heart rate
• B. Respiratory rate
• C. Blood pressure
• D. Temperature

Correct answer: B

Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.

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