Nursing Elites

1. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?

• A. Administer oxygen
• B. Stimulate the newborn
• C. Initiate positive pressure ventilation
• D. Continue routine monitoring

Correct answer: D

Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.

2. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

• A. Contact
• B. Droplet
• C. Protective
• D. Airborne

Correct answer: D

Rationale: The correct answer is D: Airborne. Tuberculosis is spread through small droplets that remain airborne for longer periods, hence requiring airborne precautions. Choice A - Contact precautions are used for diseases spread by direct or indirect contact. Choice B - Droplet precautions are for diseases transmitted by large respiratory droplets that can travel short distances. Choice C - Protective isolation is not necessary for tuberculosis, as it is not spread through contact with the client.

3. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?

• A. Take the medication with food
• B. Take the medication at bedtime
• C. Stand up slowly to prevent dizziness
• D. Increase fluid intake

Correct answer: C

Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.

4. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsening with deep breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

5. A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

• A. Adjust the flow rate of the client’s oxygen tank
• B. Collect a urine sample
• C. Measure the client’s pain level
• D. Monitor blood glucose levels

Correct answer: B

Rationale: The correct answer is B: Collect a urine sample. Delegating this task to assistive personnel is appropriate as it falls within their scope of practice. Tasks like adjusting the flow rate of oxygen tanks, measuring pain levels, and monitoring blood glucose levels require clinical judgment and should be performed by a nurse. It is important for nurses to delegate tasks that align with the competencies of assistive personnel to ensure safe and effective patient care.

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