Nursing Elites

1. The nurse is calculating the one-minute Apgar score for a newborn male infant and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant?

• A. 8
• B. 9
• C. 6
• D. 7

Correct answer: A

Rationale: The correct answer is A: 8. The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a good heart rate, vigorous cry, good muscle tone, and quick reflex irritability, which would total to 8. The only factor affecting the score is the cyanotic color, which could indicate potential respiratory or circulatory issues. Choices B, C, and D are incorrect as they do not reflect the overall assessment provided in the scenario.

2. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?

• A. The appearance of the returning dialysate fluid is cloudy
• B. The client complains of slight shortness of breath during installation
• C. The amount of the returning dialysate fluid is greater than the amount instilled
• D. The client complains of abdominal fullness and cramping during instillation

Correct answer: A

Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.

3. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

4. For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of oxygen at high levels for extended periods.
• B. Administering a sedative at bedtime to slow the client’s respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.

5. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?

• A. From the peak of one contraction to the peak of the next contraction
• B. From the beginning of one contraction to the end of that contraction
• C. From the beginning of one contraction to the beginning of the next contraction
• D. From the end of one contraction to the beginning of the next contraction

Correct answer: C

Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.

Similar Questions