Nursing Elites

1. A nurse is reviewing the laboratory results of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin 12 g/dL
• B. Glucose 50 mg/dL
• C. Bilirubin 4 mg/dL
• D. Platelets 200,000/mm³

Correct answer: C

Rationale: The correct answer is C: Bilirubin 4 mg/dL. A bilirubin level of 4 mg/dL is elevated for a newborn and requires monitoring and potential intervention to prevent complications such as jaundice and kernicterus. Elevated bilirubin levels in newborns can lead to serious neurological consequences. Choices A, B, and D are within normal ranges for a newborn and do not require immediate reporting to the provider. Therefore, the nurse should prioritize reporting the elevated bilirubin level to the provider for further evaluation and management.

2. A nurse is caring for a client receiving anticoagulation therapy. Which of the following should the nurse monitor?

• A. INR levels
• B. Blood glucose
• C. Serum creatinine
• D. Liver function

Correct answer: A

Rationale: Corrected Rationale: When caring for a client receiving anticoagulation therapy, the nurse should monitor the INR levels. INR (International Normalized Ratio) reflects the blood's ability to clot properly. It is crucial to monitor INR levels to ensure the anticoagulation therapy is within the therapeutic range and to prevent bleeding complications. Monitoring blood glucose levels (Choice B) is more relevant for clients with diabetes or those on medications affecting blood sugar. Serum creatinine (Choice C) is typically monitored to assess kidney function. Liver function (Choice D) is assessed through tests like AST, ALT, and bilirubin levels, and it is more relevant for assessing liver health rather than monitoring anticoagulation therapy.

3. A client has been diagnosed with tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?

• A. Contact precautions
• B. Airborne precautions
• C. Droplet precautions
• D. Protective environment

Correct answer: B

Rationale: Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client with TB under airborne precautions to prevent the transmission of the disease. Choice A, contact precautions, are used for diseases that spread by direct or indirect contact. Choice C, droplet precautions, are for diseases transmitted by large droplets. Choice D, protective environment, is used for clients who have compromised immune systems.

4. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

• A. Vernix caseosa
• B. Head circumference of 34 cm
• C. Jaundice at 24 hours of age
• D. Respiratory rate of 50/min

Correct answer: C

Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.

5. A client with GERD is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should take my medicine with orange juice.”
• B. “Having a bedtime snack will prevent heartburn.”
• C. “I will lie down after meals.”
• D. “I will limit activities that require bending at the waist.”

Correct answer: D

Rationale: The correct answer is D. Limiting activities that require bending at the waist can help prevent episodes of reflux in clients with GERD. Choices A, B, and C are incorrect. Taking medicine with orange juice may not be appropriate as citrus juices can aggravate GERD. Having a bedtime snack can exacerbate heartburn by increasing stomach acid production, and lying down after meals can worsen symptoms of GERD by allowing stomach acid to flow back into the esophagus.

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