Nursing Elites

1. The newborn nursery is filled to capacity. Which newborn should the nurse assess first?

• A. A three-hour-old just waking up after a period of sleep
• B. A two-day-old crying loudly
• C. A three-day-old two hours after circumcision
• D. A one-hour-old sucking his fist

Correct answer: A

Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.

2. During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?

• A. Contact the patient's physician immediately
• B. Recommend the patient lie on his right side
• C. Advise the patient to schedule a doctor's visit the next day
• D. Suggest holding the drug Azmacort

Correct answer: A

Rationale: The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.

3. The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?

• A. Alanine aminotransferase (ALT)
• B. Serum glucose
• C. Serum creatinine
• D. Serum electrolytes

Correct answer: A

Rationale: The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.

4. The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. An MRI is ordered. In reviewing the client's information, which piece of information is of concern?

• A. Allergy to shellfish
• B. Has a cardiac pacemaker
• C. A diabetic
• D. No IV access

Correct answer: B

Rationale: The correct answer is 'Has a cardiac pacemaker.' If a client with a cardiac pacemaker undergoes an MRI, the magnetic field can interfere with the pacemaker's function, leading to serious complications or even death. It is crucial to ensure that the pacemaker is compatible with MRI imaging or to consider alternative imaging modalities. The other choices, such as 'Allergy to shellfish,' 'A diabetic,' and 'No IV access,' are not direct contraindications for an MRI scan and do not pose the same level of risk as having a cardiac pacemaker.

5. A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?

• A. LOC (level of consciousness)
• B. Short-term memory
• C. Babinski sign
• D. Clonus sign

Correct answer: A

Rationale: Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.

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