Nursing Elites

1. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

• A. Respiratory rate of 60 per minute
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

2. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions should the nurse take?

• A. Apply tape to the client’s skin before surgery.
• B. Ensure the surgical suite is well-ventilated.
• C. Wrap monitoring cords with stockinette.
• D. Schedule the surgery at the end of the day.

Correct answer: C

Rationale: The correct action the nurse should take is to wrap monitoring cords with stockinette. This measure ensures that the latex in the cords does not come into contact with the client’s skin, reducing the risk of an allergic reaction. Applying tape to the client’s skin before surgery (Choice A) may expose the client to latex if the tape contains latex. Ensuring the surgical suite is well-ventilated (Choice B) is important for overall safety but does not specifically address the client's latex allergy. Scheduling the surgery at the end of the day (Choice D) is not directly related to preventing latex exposure and allergic reactions.

3. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

4. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?

• A. Flaring of the nostrils
• B. Normal respiratory rate
• C. Clear lung sounds
• D. Decreased work of breathing

Correct answer: A

Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD. In COPD, the airways are narrowed, causing difficulty in breathing, leading to increased work of breathing. Normal respiratory rate and clear lung sounds are less likely findings in a client with COPD experiencing dyspnea. Decreased work of breathing is not expected in this situation as COPD typically results in increased work of breathing.

5. To reduce the incidence of sudden infant death syndrome (SIDS), how should the parents position the newborn?

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

Correct answer: B

Rationale: The correct answer is B: Supine position. Placing the newborn on their back (supine position) is the safest sleeping position to reduce the risk of sudden infant death syndrome (SIDS). This position helps prevent airway obstruction, which can occur when infants are placed on their stomach (prone position), side (side-lying position), or in a semi-upright position (semi-Fowler's position). The prone position (choice A) is associated with an increased risk of SIDS, making it an unsafe choice. Side-lying position (choice C) and semi-Fowler's position (choice D) also pose risks of airway compromise and are not recommended for sleep positioning to prevent SIDS. Therefore, options A, C, and D are incorrect in this context.

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