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 caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?

• A. Notify security.
• B. Respectfully deny the grandparent’s request.
• C. Contact the mother for verification.
• D. Escort the grandparent and newborn to the room.

Correct answer: B

Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.

3. A healthcare professional is preparing to administer a dose of sertraline. Which of the following should the healthcare professional assess first?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Mood changes

Correct answer: A

Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.

4. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?

• A. It can cause a brown discoloration of urine
• B. It should be taken with food
• C. It has no side effects
• D. It is safe during pregnancy

Correct answer: A

Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.

5. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

• A. Using a night-light
• B. Demonstrating how to use the call light
• C. Placing the bedside table in close proximity
• D. Hourly rounding by the nurse

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

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