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 assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Serosanguineous drainage on the surgical dressing.
• B. Temperature of 37.8°C (100°F).
• C. Urine output of 75 mL in the past 4 hours.
• D. WBC count of 15,000/mm³.

Correct answer: D

Rationale: The correct answer is D. An elevated WBC count can indicate a potential infection, especially in a postoperative client. This finding should be reported to the provider for further evaluation and management. Choices A, B, and C are common occurrences in postoperative clients and may not necessarily indicate a severe issue. Serosanguineous drainage on the surgical dressing is a normal finding in the immediate postoperative period. A temperature of 37.8°C (100°F) can be a mild fever, which is common postoperatively due to the body's response to tissue injury. Urine output of 75 mL in the past 4 hours may be within normal limits for a postoperative client, especially if they are still recovering from anesthesia.

3. A nurse is assessing a client who is postoperative following a thyroidectomy. The nurse should identify which of the following findings as an indication of hypocalcemia?

• A. Tingling in the fingers.
• B. Elevated blood pressure.
• C. Positive Chvostek's sign.
• D. Positive Kernig's sign.

Correct answer: A

Rationale: The correct answer is A: Tingling in the fingers. Tingling in the fingers is a common sign of hypocalcemia, often seen after a thyroidectomy. Hypocalcemia can occur post-thyroidectomy due to inadvertent damage or removal of the parathyroid glands which regulate calcium levels. Choices B, C, and D are incorrect. Elevated blood pressure is not typically associated with hypocalcemia. Positive Chvostek's sign is a clinical sign of hypocalcemia but is usually assessed as facial muscle twitching, not tingling in the fingers. Positive Kernig's sign is a test for meningitis, not related to hypocalcemia.

4. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

• A. Hypnosis focuses on biofeedback as a relaxation technique
• B. Hypnosis promotes increased control of pain perception during contractions
• C. Hypnosis uses therapeutic touch to reduce anxiety during labor
• D. Hypnosis provides instruction to minimize pain

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

5. A nurse is providing teaching to a client who has osteoporosis about preventing fractures. Which of the following instructions should the nurse include?

• A. Increase your intake of calcium-rich foods.
• B. Avoid weight-bearing exercises.
• C. Perform weight-bearing exercises regularly.
• D. Avoid taking calcium supplements.

Correct answer: C

Rationale: The correct instruction the nurse should include is to perform weight-bearing exercises regularly. Weight-bearing exercises help maintain bone density and reduce the risk of fractures in clients with osteoporosis. Increasing intake of calcium-rich foods (Choice A) is also beneficial for bone health. Avoiding weight-bearing exercises (Choice B) is incorrect as these exercises are essential for strengthening bones. Avoiding calcium supplements (Choice D) may not be necessary if the client's dietary intake is inadequate.

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