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 nurse enters a client's room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?

• A. Close the window
• B. Evacuate the room
• C. Call the fire department
• D. Attempt to extinguish the fire

Correct answer: B

Rationale: The correct answer is to evacuate the room first. In a fire situation, the priority is safety, following the RACE protocol: Rescue, Alarm, Contain, Extinguish. Evacuating the room ensures the safety of both the client and the nurse. Closing the window (Choice A) can wait until after evacuation when there is no immediate danger. Calling the fire department (Choice C) is important but comes after ensuring personal safety and evacuating. Attempting to extinguish the fire (Choice D) is not recommended as it can put the nurse and the client at risk; firefighting should be left to professionals.

3. A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.

4. A healthcare provider is providing education to a client about atorvastatin. Which of the following should be included?

• A. Monitor for muscle pain
• B. Avoid sun exposure
• C. Report any gastrointestinal symptoms
• D. Check liver function tests

Correct answer: A

Rationale: Corrected Rationale: Atorvastatin can cause muscle pain and liver function abnormalities. Monitoring for muscle pain is essential as it can be a sign of a serious side effect called rhabdomyolysis. While liver function tests are necessary before starting atorvastatin, checking them continuously may not be required. Avoiding sun exposure and reporting gastrointestinal symptoms are not directly associated with atorvastatin use.

5. A client with heart failure is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?

• A. I will weigh myself once a week.
• B. I will take my diuretic medication in the evening.
• C. I will limit my fluid intake to 3 liters per day.
• D. I will call my doctor if I notice swelling in my feet.

Correct answer: D

Rationale: The correct answer is D. Swelling in the feet can indicate worsening heart failure due to fluid retention, and clients should report this to their healthcare provider immediately. Choices A, B, and C are incorrect because weighing once a week may not provide timely information on fluid retention, timing of diuretic medication is usually advised in the morning to prevent nocturia, and limiting fluid intake to 3 liters per day may not be appropriate for all clients with heart failure.

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