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 ulcerative colitis has a new prescription for sulfasalazine. What adverse effect should the client monitor for according to the nurse?

• A. Jaundice
• B. Constipation
• C. Oral candidiasis
• D. Sedation

Correct answer: A

Rationale: The correct answer is A: Jaundice. Sulfasalazine can lead to liver toxicity, making it essential to monitor for jaundice, a sign of liver dysfunction. Choices B, C, and D are incorrect because constipation, oral candidiasis, and sedation are not commonly associated with sulfasalazine use.

3. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?

• A. Serum sodium 138 mEq/L
• B. Urine specific gravity 1.001
• C. Serum calcium 10 mg/dL
• D. Urine pH 6

Correct answer: B

Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.

4. A nurse is assessing a client who has schizophrenia and is experiencing negative symptoms. Which of the following findings should the nurse expect?

• A. Hallucinations
• B. Delusions
• C. Flat affect
• D. Paranoia

Correct answer: C

Rationale: The correct answer is C: Flat affect. Negative symptoms of schizophrenia involve deficits in normal emotional responses or other thought processes. These symptoms include a flat affect (reduced emotional expression), social withdrawal, and avolition (lack of motivation). Hallucinations and delusions are characteristic of positive symptoms, which involve the presence of abnormal behaviors or experiences. Paranoia is more associated with delusions rather than negative symptoms.

5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?

• A. Pinch the skin and inject at a 45-degree angle
• B. Massage the injection site after administering
• C. Administer at a 90-degree angle
• D. Avoid rotating injection sites

Correct answer: A

Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.

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