Nursing Elites

1. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Auscultate the newborn's apical pulse for 60 seconds
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence

Correct answer: C

Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.

2. A nurse is caring for a client who has a prescription for a low-sodium diet. Which of the following foods should the nurse recommend?

• A. Pickles
• B. Fresh vegetables
• C. Canned soup
• D. Smoked salmon

Correct answer: B

Rationale: Fresh vegetables are an excellent choice for clients on a low-sodium diet as they are naturally low in sodium. Pickles, canned soup, and smoked salmon are high in sodium and should be avoided by clients following a low-sodium diet. Pickles are pickled in a brine solution high in sodium, canned soup usually contains added salt for preservation, and smoked salmon is a processed food that typically has a high sodium content.

3. A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?

• A. Place the mouthpiece in your mouth and blow out as quickly as you can.
• B. Exhale slowly into the mouthpiece over 5 seconds.
• C. Take a slow deep breath before blowing into the mouthpiece.
• D. Blow into the mouthpiece at a steady rate for 3 seconds.

Correct answer: A

Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.

4. A client is receiving discharge teaching for a new prescription of metformin. Which of the following client statements demonstrates an understanding of the teaching?

• A. I will take this medication with my meals.
• B. I will take this medication at the same time every day.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will expect to experience weight gain while taking this medication.

Correct answer: C

Rationale: The correct answer is C because clients taking metformin should avoid alcohol as it increases the risk of lactic acidosis. Choices A, B, and D are incorrect. Choice A is not specific to metformin but rather a general recommendation for some medications. Choice B is a good practice for medication adherence but does not relate specifically to metformin. Choice D is inaccurate as weight gain is not an expected side effect of metformin.

5. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?

• A. Gastric pH of 2.5.
• B. Bowel sounds every 4 hours.
• C. Diarrhea of 250 mL in 24 hours.
• D. Gastric residual of 150 mL.

Correct answer: D

Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.

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