Nursing Elites

1. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?

• A. Respiratory rate of 60/min
• B. Jitteriness of the hands
• C. Diaphoresis
• D. Bounding peripheral pulses

Correct answer: B

Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.

2. A nurse is reviewing laboratory results for a client who has chronic kidney disease. Which of the following findings should the nurse expect?

• A. Hypernatremia
• B. Hypocalcemia
• C. Low potassium
• D. Low magnesium

Correct answer: B

Rationale: In chronic kidney disease, the kidneys have impaired ability to activate vitamin D, leading to decreased production of calcitriol. Calcitriol is essential for calcium absorption in the intestines. Therefore, hypocalcemia is a common finding in chronic kidney disease. Hypernatremia (increased sodium levels) is not typically associated with chronic kidney disease. Low potassium and low magnesium are possible electrolyte imbalances in chronic kidney disease, but they are not as directly related to the impaired activation of vitamin D as hypocalcemia.

3. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?

• A. Sudden weight loss
• B. Regular contractions
• C. Shortness of breath
• D. Vaginal spotting

Correct answer: B

Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.

4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?

• A. Pinch the skin and inject at a 45-degree angle
• B. Massage the injection site after administering
• C. Administer at a 90-degree angle
• D. Avoid rotating injection sites

Correct answer: A

Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.

5. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?

• A. Nausea and vomiting
• B. Increased urination
• C. Tremors
• D. Blurred vision

Correct answer: C

Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.

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