Nursing Elites

1. A nurse is caring for a newborn immediately following birth. What should the nurse do first?

• A. Instill erythromycin ophthalmic ointment
• B. Place identification bracelets on the newborn
• C. Weigh the newborn
• D. Dry the newborn

Correct answer: D

Rationale: Drying the newborn is the first priority to prevent heat loss, which can occur rapidly in newborns due to their large surface area and lack of body fat. This helps maintain the newborn's body temperature and prevent hypothermia. Instilling erythromycin ophthalmic ointment, placing identification bracelets, and weighing the newborn can be important steps but should come after ensuring the newborn is dried to maintain their body temperature.

2. A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to evaluate the effectiveness of the medication?

• A. Respiratory rate
• B. Blood pressure
• C. Apical pulse
• D. Urine output

Correct answer: C

Rationale: The correct answer is C: Apical pulse. Digoxin's primary effect is to strengthen the force of the heart's contractions and slow the heart rate. Monitoring the apical pulse is crucial in evaluating the effectiveness of digoxin as it helps assess the medication's impact on the heart's function. Option A, respiratory rate, is not directly related to digoxin's mechanism of action and is not the most appropriate parameter to monitor for this medication. Option B, blood pressure, while important, may not be as sensitive as the apical pulse in assessing the effectiveness of digoxin. Option D, urine output, is more indicative of kidney function and fluid balance, rather than the direct effectiveness of digoxin in heart failure.

3. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

4. A healthcare provider is preparing to administer an influenza vaccine to an adult client. Which of the following is a contraindication?

• A. Client has a low-grade fever
• B. Client is allergic to eggs
• C. Client had recent surgery
• D. Client is on corticosteroid therapy

Correct answer: B

Rationale: The correct answer is B: Client is allergic to eggs. The influenza vaccine is contraindicated in individuals with an allergy to eggs because some influenza vaccines are produced using egg-based processes. Choices A, C, and D are not contraindications for administering the influenza vaccine. A low-grade fever, recent surgery, and corticosteroid therapy are not contraindications for receiving the influenza vaccine.

5. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?

• A. Clamp the chest tube intermittently.
• B. Keep the drainage system below chest level.
• C. Empty the drainage chamber every 4 hours.
• D. Apply sterile gauze around the insertion site daily.

Correct answer: B

Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.

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