Nursing Elites

1. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

• A. Pink lips and tongue with cyanotic hands and feet
• B. Respiration rate of 40 and heart rate of 144
• C. Centralized cyanosis and tachycardia when crying
• D. Desquamation from areas of cracked, parchment-like skin

Correct answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

2. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?

• A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
• B. Ambulatory following coronary artery bypass graft surgery performed six days ago
• C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
• D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea

Correct answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

3. A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?

• A. Refer the client to a healthcare provider for a pelvic examination
• B. Notify the parents that the client needs to be picked up from school
• C. Determine the date of the client's last menstrual period
• D. Ask the client to lie down for a pelvic examination

Correct answer: A

Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.

4. The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?

• A. Administer an antiemetic before meals
• B. Provide frequent mouth care
• C. Encourage small, frequent meals
• D. Offer clear liquids

Correct answer: A

Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics help prevent or reduce nausea and vomiting associated with chemotherapy. Providing frequent mouth care (choice B) is important for managing oral mucositis but not specifically for nausea. Encouraging small, frequent meals (choice C) and offering clear liquids (choice D) are beneficial strategies for managing gastrointestinal side effects but may not be as effective in controlling nausea as administering antiemetics.

5. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct calculation for infusion based on the given data is 5 ml/hr. To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour. Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.

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