Nursing Elites

1. After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?

• A. heart rate, respiratory effort, color, muscle tone, reflex irritability
• B. heart rate, bleeding, cyanosis, edema
• C. bleeding, reflex, edema
• D. respiratory effort, heart rate, seizures

Correct answer: B

Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.

2. Which of the following is an indication for electroencephalography?

• A. paralysis
• B. neuropathy
• C. seizure disorder
• D. myocardial infarction

Correct answer: C

Rationale: The correct answer is C: 'seizure disorder.' Electroencephalography is used to assess clients with seizure disorders by recording the brain's electrical activity. Seizure disorder is a primary indication for an EEG as it helps in diagnosing and managing seizure activity. Paralysis (choice A) is not typically an indication for an EEG as it relates to loss of muscle function rather than brain activity. Neuropathy (choice B) involves nerve damage and is not directly assessed by an EEG. Myocardial infarction (choice D) is related to heart issues and is not a condition that an EEG is used to diagnose.

3. Which of these types of fluid output is not typically measured?

• A. chest tube drainage
• B. emesis
• C. evaporative water from the respiratory tract
• D. urine

Correct answer: D

Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.

4. Which of the following lab values is elevated first after a client has a myocardial infarction?

• A. LDH
• B. troponin
• C. CPK
• D. SGOT

Correct answer: B

Rationale: The correct answer is troponin. Troponin levels are the most specific and sensitive markers for myocardial infarction, and they begin to rise within a few hours after the event. CPK, SGOT, and LDH are also enzymes that can indicate myocardial damage, but troponin is the earliest and most specific indicator. CPK typically rises 4-8 hours after an infarction, followed by SGOT (AST) at 8-12 hours, and LDH at 12-24 hours post-infarction.

5. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.

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