Nursing Elites

1. You are caring for a patient who just gave birth to a 6 lb. 13 oz. baby boy. The infant gave out a lusty cry, had a pink coloration all over his body, had flexed arms and legs, cried when stimulated, and had a pulse rate of 94. What Apgar score would you expect for this baby?

• A. 10
• B. 8
• C. 7
• D. 9

Correct answer: D

Rationale: The Apgar score is a method used to quickly assess the health of newborns. In this scenario, the baby would receive 2 points for color, reflex irritability, and muscle tone, but only 1 point for a pulse rate of 94, resulting in an Apgar score of 9. An Apgar score of 9 indicates that the baby is in good health overall. Choice A (10) is incorrect because a pulse rate of 94 would only score 1 point. Choices B (8) and C (7) are incorrect as the given criteria would lead to a higher score, indicating the baby's good health.

2. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?

• A. Stop the procedure and tell the UAP to place the client in a Fowler's position
• B. Praise the UAP for doing the oral hygiene but encourage family participation
• C. Tell the UAP to continue because the unconscious client is positioned safely
• D. Enroll the UAP in a hospital education class on conducting safe client care

Correct answer: C

Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.

3. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?

• A. Massage the calf and foot
• B. Elevate the leg above the heart
• C. Check the pedal pulse in the affected leg
• D. Extend the leg and flex the foot

Correct answer: D

Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.

4. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?

• A. Tingling in the hands and around the mouth.
• B. Nausea and vomiting.
• C. Constipation.
• D. Bradycardia.

Correct answer: A

Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.

5. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

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