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. Major competencies for the nurse giving end-of-life care include:

• A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
• B. assessing and intervening to support total management of the family and client.
• C. setting goals, expectations, and dynamic changes to care for the client.
• D. keeping all sad news away from the family and client.

Correct answer: A

Rationale: In providing end-of-life care, nurses must possess essential competencies. Demonstrating respect and compassion, along with applying knowledge and skills in caring for both the family and the client, are crucial competencies. These skills help create a supportive and empathetic environment for individuals facing end-of-life situations. Choice B is incorrect because while assessing and intervening are important, they do not encompass the core competencies required for end-of-life care. Choice C is also incorrect; although setting goals and expectations is valuable, the primary focus should be on providing compassionate care. Choice D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.

3. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?

• A. Nurse Christine should offer to give medications to Nurse Ann's other two clients.
• B. Nurse Christine should inform their supervisor that assignments may need to be changed.
• C. Nurse Christine should ask other nurses who might be able to help Nurse Ann.
• D. Nurse Ann should try not to burden other nurses and continue caring for her assigned clients.

Correct answer: B

Rationale: In this situation, when Nurse Ann informs Nurse Christine that a client's status is declining and she needs to attend to them, the most appropriate action for Nurse Christine is to inform their supervisor that assignments may need to be changed. By informing the supervisor, necessary adjustments can be made to ensure proper care for all clients. Offering to give medications to Nurse Ann's other two clients (choice A) may not address the underlying issue of a declining client and could lead to a delay in care. Asking other nurses for help (choice C) might not be the most efficient solution, as the supervisor is responsible for reassigning tasks. Nurse Ann continuing to care for all her assigned clients (choice D) may compromise the quality of care provided to the declining client and may spread her too thin, impacting all clients negatively.

4. When are standard walkers typically used?

• A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
• B. When clients have poor balance, have a broken leg, or have experienced amputation.
• C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
• D. When clients have poor balance, have an autoimmune disease, or have weak arms.

Correct answer: C

Rationale: Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.

5. A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first?

• A. A client scheduled for hemodialysis at 10 a.m.
• B. A client scheduled for contrast computed tomography (CT) at noon.
• C. A client scheduled for a nuclear scanning procedure at 10 a.m.
• D. A client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m.

Correct answer: A

Rationale: The correct answer is the client scheduled for hemodialysis at 10 a.m. This client needs immediate assessment before the procedure, which may take up to 5 hours. The nurse should ensure the client is physically and emotionally prepared, check for fluid overload by assessing weight and lung sounds, review vital signs, and laboratory test results. The other clients described in the options have needs that are not as urgent. The client scheduled for a nuclear scanning procedure at 10 a.m. may require information reinforcement and increased fluid intake before the procedure. The client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m. may need pain medication administered 30 minutes prior to the therapy. The client scheduled for a contrast CT at noon may need procedure information reinforcement and a special contrast preparation just before the procedure.

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