Nursing Elites

1. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?

• A. Administer oxygen
• B. Stimulate the newborn
• C. Initiate positive pressure ventilation
• D. Continue routine monitoring

Correct answer: D

Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.

2. When teaching a client about the use of risperidone, which of the following should be included?

• A. It is an SSRI
• B. Monitor for metabolic syndrome
• C. It has no side effects
• D. It can be taken with alcohol

Correct answer: B

Rationale: The correct answer is B: 'Monitor for metabolic syndrome.' Risperidone is not an SSRI but an atypical antipsychotic. Choice A is incorrect. Choice C is also incorrect as risperidone, like any medication, can have side effects. Choice D is wrong because alcohol consumption should generally be avoided while taking risperidone. Educating clients about monitoring for metabolic syndrome, weight gain, and other potential side effects is crucial in managing their health effectively while on this medication.

3. A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?

• A. You should keep the car seat rear-facing until your baby is at least 2 years old.
• B. Position the retainer clip over the upper part of your baby's abdomen.
• C. You should place your baby in the car seat with a slight recline.
• D. Place the shoulder harness straps in the slots at or below your baby's shoulders.

Correct answer: A

Rationale: The correct answer is A. The car seat should remain rear-facing until the baby is at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant’s head, neck, and spine. Choice B is incorrect because the retainer clip should be positioned at armpit level on the baby, not over the upper part of the abdomen. Choice C is incorrect as the baby should be placed in the car seat with a slight recline, not at a 90-degree angle. Choice D is incorrect as the shoulder harness straps should be at or below the baby's shoulders, not above, to ensure proper fit and safety.

4. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Increased blood pressure
• C. Tachypnea
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.

5. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?

• A. Obtain the client's consent
• B. Verify the blood type and crossmatch
• C. Take baseline vital signs
• D. Prime the IV with normal saline

Correct answer: B

Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.

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