Nursing Elites

1. Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?

• A. Cold stress
• B. Hyperthermia
• C. Dehydration
• D. Hypoxia

Correct answer: A

Rationale: Placing the newborn under a radiant heat warmer is used to prevent cold stress. Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature, potentially resulting in hypoglycemia and metabolic acidosis if not addressed. The radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications. Choices B, C, and D are incorrect because the primary purpose of using a radiant warmer in this scenario is to prevent cold stress specifically, not hyperthermia, dehydration, or hypoxia.

2. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

• A. Respiratory rate of 60 per minute
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

3. A client has been prescribed metformin. What should be included in the teaching?

• A. It can cause weight gain
• B. Take it with food
• C. It is an insulin
• D. Monitor for hyperglycemia

Correct answer: B

Rationale: The correct answer is to take metformin with food. This is important to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect as metformin is not typically associated with weight gain. Choice C is wrong as metformin is not an insulin but a medication that helps control blood sugar levels. Choice D is also incorrect as metformin is not known to cause hyperglycemia.

4. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

5. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?

• A. Restrain the client
• B. Place the client on their side with their head forward
• C. Perform a neurological assessment
• D. Monitor the client's vitals every 2 minutes

Correct answer: B

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.

Similar Questions