Nursing Elites

1. A nurse is assessing a newborn who is 10 hours old. Which of the following findings should the nurse report to the provider?

• A. Axillary temperature 36.5°C (97.7°F)
• B. Nasal flaring
• C. Heart rate 158/min
• D. One void since birth

Correct answer: B

Rationale: Nasal flaring can indicate respiratory distress in a newborn, which is a critical finding requiring immediate attention. This may suggest an issue with breathing or lung function. Reporting nasal flaring promptly allows the provider to assess and intervene to ensure the newborn's respiratory status is stable. Choices A, C, and D are within normal parameters for a 10-hour-old newborn and do not indicate an immediate concern. An axillary temperature of 36.5°C (97.7°F) is within the normal range for a newborn. A heart rate of 158/min is typical for a newborn, and one void since birth is an expected finding at this early stage.

2. A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

• A. Increased fiber intake
• B. Suppression of the urge to defecate
• C. Ambulation twice a day
• D. Daily laxative use

Correct answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

3. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?

• A. Taking the medication with water
• B. Skipping doses of medication
• C. A history of recurring bowel inflammation
• D. Taking anti-inflammatory medication without food

Correct answer: C

Rationale: The correct answer is C. A history of recurring bowel inflammation can impact the absorption and effectiveness of arthritis medication. Bowel inflammation can affect the body's ability to absorb the medication properly, leading to decreased effectiveness. Choices A, B, and D do not directly relate to the decreased effectiveness of the arthritis medication. Taking medication with water, skipping doses, or taking anti-inflammatory medication without food may not be ideal practices but are not directly linked to the decrease in effectiveness reported by the client.

4. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

• A. Ensure the environment is safe
• B. Administer medications as prescribed
• C. Monitor for signs of infection
• D. Educate the client about triggers

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

5. A healthcare professional is preparing to administer a dose of nitroglycerin. Which of the following should be assessed first?

• A. Blood pressure
• B. Heart rate
• C. Pain level
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is to assess blood pressure first before administering nitroglycerin. Nitroglycerin is a vasodilator that can cause a sudden drop in blood pressure, leading to adverse effects such as dizziness or fainting. Assessing blood pressure before administration helps determine if the patient's blood pressure is within the acceptable range for nitroglycerin administration. Heart rate, pain level, and respiratory rate are also important assessments, but blood pressure should take precedence due to the vasodilating effects of nitroglycerin.

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