Nursing Elites

1. A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?

• A. Place the newborn under a radiant warmer
• B. Apply oxygen
• C. Swaddle the newborn
• D. Reassess the newborn in 1 hour

Correct answer: D

Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding in newborns within the first few hours after birth. The heart rate of 130 beats per minute is also within the normal range for a newborn. These findings are typical and do not require immediate intervention. The appropriate action for the nurse is to continue monitoring the newborn. Reassessing the newborn in 1 hour allows the nurse to observe any changes and ensure the newborn's condition remains stable. Placing the newborn under a radiant warmer or applying oxygen is not necessary as the newborn's condition is within normal limits. Swaddling the newborn may provide comfort but is not the priority action in this scenario.

2. A client with chronic kidney disease is about to start hemodialysis. Which of the following instructions should the nurse include?

• A. Increase protein intake between dialysis sessions
• B. Reduce potassium intake
• C. Avoid iron supplements
• D. Expect weight gain after each dialysis session

Correct answer: B

Rationale: The correct answer is to instruct the client to reduce potassium intake. Clients with chronic kidney disease should limit potassium intake to prevent hyperkalemia, as the kidneys may struggle to remove excess potassium. Increasing protein intake between dialysis sessions (Choice A) is not recommended as it can increase urea production, adding to the workload of the kidneys. Avoiding iron supplements (Choice C) is not necessary unless iron levels are high. Expecting weight gain after each dialysis session (Choice D) is incorrect as patients typically experience weight loss due to fluid removal during dialysis.

3. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?

• A. I will notify my doctor if I develop a cough.
• B. I will avoid using salt substitutes.
• C. I will increase my intake of potassium-rich foods.
• D. I will monitor my blood pressure regularly.

Correct answer: C

Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.

4. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Weight gain
• C. Decreased urination
• D. Fatigue

Correct answer: A

Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.

5. A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?

• A. Check the expiration date
• B. Verify the client's blood glucose level
• C. Obtain the client's weight
• D. Assess for signs of hypoglycemia

Correct answer: B

Rationale: The correct answer is to verify the client's blood glucose level first before administering insulin. This step is crucial to determine the appropriate dose of insulin based on the client's current blood glucose level. Checking the expiration date (Choice A) is important but not the first step in this scenario. Obtaining the client's weight (Choice C) is not directly related to the immediate administration of insulin. Assessing for signs of hypoglycemia (Choice D) should be done after administering insulin to monitor for potential side effects or adverse reactions.

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