Nursing Elites

1. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

• A. Axillary temperature 36.5°C (97.7°F)
• B. Nasal flaring
• C. Heart rate 158/min
• D. One void since birth

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

2. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?

• A. Heart rate 120/min
• B. Urine output 30 mL/hour
• C. Blood pressure 110/70 mmHg
• D. Skin turgor is normal

Correct answer: A

Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.

3. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?

• A. Report of fatigue and fever
• B. Report of muscle twitching and skin rash
• C. Report of blurred vision
• D. Report of nasal congestion

Correct answer: B

Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.

4. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Increased blood pressure
• C. Tachypnea
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.

5. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

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