Nursing Elites

1. Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?

• A. Place a pulse oximeter on the heel
• B. Swaddle the infant in a warm blanket
• C. Record the findings on the flow sheet
• D. Check the vital signs in 15 minutes

Correct answer: C

Rationale: The correct answer is to record the findings on the flow sheet. These assessment findings are within normal limits for a 3-hour-old newborn. The axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate of 42 breaths/min are all expected in a newborn. No immediate intervention is needed, so the nurse should document these normal findings for future reference. Placing a pulse oximeter on the heel or swaddling the infant in a warm blanket is not indicated as the vital signs are within normal limits. Checking the vital signs in 15 minutes is unnecessary since the current findings are normal.

2. The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

• A. Client reports itching under the cast
• B. Client reports pain at the cast site
• C. Client reports swelling of the fingers
• D. Client reports warmth over the casted area

Correct answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

3. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

• A. The client is experiencing increased intracranial pressure
• B. He has a good prognosis for recovery
• C. This client is conscious, but is not oriented to time and place
• D. He is in a coma, and has a very poor prognosis

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?

• A. Increase the oxygen flow rate
• B. Instruct the client to breathe deeply and cough
• C. Check the client's oxygen saturation level
• D. Place the client in a high-Fowler's position

Correct answer: C

Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.

5. A client who is 12-hours post-op following a left hip replacement has an indwelling urinary catheter. The nurse determines that the client's urinary output is 60 ml in the past 3 hours. What action should the nurse take first?

• A. Assess the client's vital signs
• B. Irrigate the catheter with 30 ml of sterile normal saline
• C. Notify the healthcare provider
• D. Replace the catheter with a larger size

Correct answer: A

Rationale: In a client post-op with low urinary output, the first action the nurse should take is to assess the client's vital signs. Vital signs can provide valuable information about the client's overall condition, fluid status, and potential complications. Assessing the vital signs can help the nurse to determine if the low urine output is indicative of a larger issue that needs immediate attention. Irrigating the catheter with normal saline may be necessary but should not be the first action without assessing the client. Notifying the healthcare provider should follow assessment if there are concerns. Replacing the catheter with a larger size is not indicated solely based on low urinary output and should not be the first action taken.

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