Nursing Elites

1. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

2. What is the best position for a patient in respiratory distress?

• A. Semi-Fowler's position
• B. Trendelenburg position
• C. Prone position
• D. Supine position

Correct answer: A

Rationale: The best position for a patient in respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and eases breathing by allowing the chest to expand more fully. The Trendelenburg position (choice B) where the patient's feet are higher than the head is not recommended in respiratory distress as it may cause increased pressure on the chest and reduced lung expansion. The prone position (choice C) lying on the stomach is also not optimal for respiratory distress as it can further compromise breathing. The supine position (choice D) lying flat on the back is not ideal as it may impair breathing by restricting chest expansion.

3. A healthcare provider is planning care for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the healthcare provider include?

• A. Administer 0.9% sodium chloride with the TPN.
• B. Change the TPN tubing every 24 hours.
• C. Weigh the client every 72 hours.
• D. Flush the TPN line with heparin.

Correct answer: B

Rationale: The correct action the healthcare provider should include is changing the TPN tubing every 24 hours to decrease the risk of infection. Administering 0.9% sodium chloride with TPN is not typically recommended as it can cause chemical instability. Weighing the client every 72 hours is important but not directly related to TPN administration. Flushing the TPN line with heparin is not a standard practice and not recommended as it can increase the risk of complications.

4. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

• A. Discontinue oxytocin infusion
• B. Increase oxytocin infusion
• C. Decrease oxytocin infusion
• D. Maintain oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

5. What is the most appropriate method to assess a patient's level of consciousness?

• A. Use the Glasgow Coma Scale
• B. Assess the patient's orientation
• C. Check pupillary response
• D. Monitor vital signs

Correct answer: A

Rationale: The correct answer is A: Using the Glasgow Coma Scale. The Glasgow Coma Scale is a standardized tool used to assess a patient's level of consciousness by evaluating their eye response, verbal response, and motor response. This scale provides a numeric value that helps in determining the severity of brain injury or altered mental status. Choices B, C, and D are incorrect because while assessing the patient's orientation, checking pupillary response, and monitoring vital signs are important components of a comprehensive patient assessment, they do not specifically target the assessment of consciousness level, which is best done using the Glasgow Coma Scale.

Similar Questions