Nursing Elites

1. A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. What is the most appropriate action for the nurse to take?

• A. Initiate cardiopulmonary resuscitation
• B. Gently stimulate the infant by rubbing his back while administering oxygen
• C. Recheck the score in 5 minutes
• D. Provide no action except to support the infant's spontaneous efforts

Correct answer: B

Rationale: The Apgar score is a method for rapidly evaluating an infant's cardiorespiratory adaptation after birth. The nurse assigns scores in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color, totaling the scores. A score of 8 to 10 requires no action other than supporting the infant's spontaneous efforts and observation. A score of 4 to 7 indicates the need to gently stimulate the infant by rubbing his back while administering oxygen. If the score is 1 to 3, the infant requires resuscitation. Therefore, in this scenario with an Apgar score of 6, the correct action is to gently stimulate the infant by rubbing his back while administering oxygen. Initiating cardiopulmonary resuscitation would be excessive at this point, and rechecking the score in 5 minutes may delay necessary interventions. Providing no action except to support the infant's spontaneous efforts is insufficient for a score of 6, indicating the need for stimulation and oxygen administration.

2. Which of the following would likely not impede learning?

• A. a client who took Ambien� an hour ago
• B. a bipolar client currently in a manic phase
• C. a client who states they are not interested
• D. a client with dysphagia

Correct answer: C

Rationale: The correct answer is a client who states they are not interested. While lack of interest can hinder learning motivation, it is not a physical or mental barrier that directly impacts the learning process. On the other hand, a client who took Ambien� an hour ago may experience drowsiness or impaired cognitive function, affecting their ability to learn. A bipolar client in a manic phase may exhibit symptoms such as racing thoughts, distractibility, and impulsivity, making it challenging for them to focus and engage in the learning process. A client with dysphagia may have difficulty swallowing, which can interfere with their ability to take oral medications or participate in activities that involve swallowing.

3. The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?

• A. Ask the healthcare provider about referring the client to a neurological specialist.
• B. Obtain a prescription for a muscle relaxant.
• C. Notify the healthcare provider immediately.
• D. Document the findings.

Correct answer: D

Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.

4. How often should the intravenous tubing on total parenteral nutrition solutions be changed?

• A. every 24 hours
• B. every 36 hours
• C. every 48 hours
• D. every 72 hours

Correct answer: A

Rationale: The correct answer is to change the intravenous tubing on total parenteral nutrition solutions every 24 hours. This frequency is necessary due to the high risk of bacterial growth associated with TPN solutions. Changing the tubing every 24 hours helps prevent contamination and bloodstream infections. Choices B, C, and D are incorrect because waiting longer intervals increases the risk of introducing harmful bacteria into the patient's system, leading to potentially severe complications.

5. When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:

• A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
• B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
• C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
• D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?

Correct answer: D

Rationale: The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.

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