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 are the signs and symptoms of fluid overload, and how should a nurse manage this condition?

• A. Edema, weight gain, shortness of breath
• B. Fever, cough, chest pain
• C. Increased heart rate, low blood pressure
• D. Increased blood pressure, jugular venous distention

Correct answer: A

Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.

3. A client receiving chemotherapy for cancer has developed stomatitis. Which of the following interventions should the nurse implement?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct intervention for a client with stomatitis, a common side effect of chemotherapy, is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the mouth. Providing lemon-glycerin swabs (choice A) can be too harsh and irritating to the mouth. Avoiding toothpaste (choice C) is not necessary unless it contains harsh ingredients that can further irritate the mouth. Instructing the client to use a mouthwash containing alcohol (choice D) is contraindicated as alcohol-containing mouthwashes can be too harsh and drying for clients with stomatitis.

4. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, 'She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.' Which suggestions should the nurse make to the daughter?

• A. Ask the client's physician for a strong sleep medicine
• B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime
• C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day
• D. Promote relaxation before bedtime with a warm bath or relaxing music

Correct answer: B

Rationale: The correct answer is to establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. By creating a structured daily schedule, the client's natural sleep-wake cycle can be regulated, helping to address the issue of daytime sleeping and nighttime wakefulness. Option A, asking for a strong sleep medicine, may not address the underlying cause and can have potential side effects in the elderly. Option C, engaging in exercises when drowsy, may not be suitable for someone with dementia and could disrupt sleep patterns further. Option D, promoting relaxation before bedtime, is helpful but may not be sufficient to address the client's significant sleep issue.

5. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?

• A. Threatening to withhold food from a client
• B. Informing a client about an upcoming procedure
• C. Informing a client about risks of refusing treatment
• D. Informing a client that they will be given an injection against their will

Correct answer: D

Rationale: The correct answer is D because assault involves threatening a client with harm or unwanted procedures. In this scenario, informing a client that they will be given an injection against their will constitutes assault. Choices A, B, and C do not involve the element of threatening harm or unwanted procedures, making them incorrect. Choice A is more related to neglect, choice B is related to informing the client about a procedure, and choice C is related to informed consent and refusal of treatment, not assault.

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