Nursing Elites

1. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

• A. Notify the pediatrician immediately.
• B. Teach the parents about congenital heart defects.
• C. Document the finding in the infant's record.
• D. Apply oxygen via nasal cannula at 3 L/min.

Correct answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

2. When administering ceftriaxone sodium (Rocephin) intravenously to a client, which finding requires the most immediate intervention by the nurse?

• A. Stridor
• B. Nausea
• C. Headache
• D. Pruritus

Correct answer: A

Rationale: The correct answer is A: Stridor. Stridor indicates bronchospasm, a serious reaction that can compromise the client's airway. Immediate intervention is crucial to prevent further respiratory distress. Nausea, headache, and pruritus are potential side effects of ceftriaxone but are not as immediately life-threatening as airway compromise indicated by stridor.

3. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

• A. Blood pressure 90/76 mm Hg.
• B. Heart rate of 85 bpm.
• C. Respiratory rate of 20 breaths/minute.
• D. Temperature of 99°F (37.2°C).

Correct answer: A

Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.

4. A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Total calcium 5.0 mg/dL.
• B. Serum sodium 140 mEq/L.
• C. Serum potassium 4.0 mEq/L.
• D. Serum glucose 90 mg/dL.

Correct answer: A

Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.

5. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?

• A. Sitting up and leaning forward
• B. Lying flat with legs elevated
• C. Lying on the side with the head slightly raised
• D. Sitting up and tilting the head back

Correct answer: A

Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.

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