Nursing Elites

1. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

2. What is the main symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Increased heart rate
• D. Decreased urine output

Correct answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.

3. A client is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent dislocation of the prosthesis?

• A. Encourage the client to bend at the waist
• B. Maintain the client in a high-Fowler's position
• C. Place a pillow between the client's legs
• D. Avoid placing a pillow under the client's knees

Correct answer: C

Rationale: Placing a pillow between the client's legs is beneficial after hip replacement surgery to maintain proper alignment and prevent dislocation of the prosthesis. This position helps keep the hip in a neutral position, reducing the risk of dislocation. Encouraging the client to bend at the waist (Choice A) can increase the risk of hip dislocation. Maintaining the client in a high-Fowler's position (Choice B) and avoiding placing a pillow under the client's knees (Choice D) do not directly address the need to maintain proper alignment of the hip joint to prevent dislocation.

4. A charge nurse on a long-term care unit is preparing to delegate tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the charge nurse delegate to the LPN?

• A. Insert an IV catheter
• B. Administer initial NG tube feeding
• C. Administer insulin
• D. Give medications for diabetes

Correct answer: B

Rationale: The correct task to delegate to the LPN is administering initial NG tube feeding. LPNs are trained to carry out this task as it falls within their scope of practice. Inserting an IV catheter (Choice A) is typically performed by registered nurses. Administering insulin (Choice C) and giving medications for diabetes (Choice D) involve assessing the patient's condition and adjusting medication dosage, which are responsibilities of registered nurses or higher-level healthcare providers.

5. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

• A. Total bilirubin.
• B. Urine ketones.
• C. Serum potassium.
• D. Platelet count.

Correct answer: C

Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.

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