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. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?

• A. Extinguish the fire
• B. Activate the fire alarm
• C. Evacuate the room
• D. Call the client’s family

Correct answer: C

Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.

3. A nurse is preparing to administer furosemide to a client who has a prescription. Which of the following statements by the client indicates a need for further teaching?

• A. I will take my morning pills with food or milk.
• B. I will weigh myself every day.
• C. I will notify the nurse if I have muscle cramps.
• D. I will limit my intake of fish.

Correct answer: D

Rationale: The correct answer is D. There is no need to limit fish intake with furosemide, indicating a misunderstanding of dietary restrictions. Furosemide is a diuretic that helps the body get rid of excess water and salt. Choices A, B, and C are all appropriate actions for a client taking furosemide. Taking morning pills with food or milk can help reduce stomach upset, weighing oneself daily helps monitor fluid retention, and notifying the nurse about muscle cramps can be important due to potential electrolyte imbalances.

4. A healthcare provider is assessing a client who is receiving IV gentamicin three times daily. Which of the following findings indicates that the client is experiencing an adverse effect of this medication?

• A. Hypoglycemia
• B. Proteinuria
• C. Nasal congestion
• D. Visual disturbances

Correct answer: B

Rationale: Corrected Rationale: Gentamicin is known to cause nephrotoxicity as an adverse effect. Proteinuria, which is the presence of excess proteins in the urine, may indicate kidney damage from the medication. Monitoring renal function is crucial in clients receiving gentamicin. Choice A, hypoglycemia, is not a typical adverse effect of gentamicin. Choices C and D, nasal congestion and visual disturbances, are not commonly associated with gentamicin use or its adverse effects.

5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?

• A. Inflate the balloon with 10 mL of sterile water prior to insertion
• B. Cleanse the client’s labia and meatus using a front-to-back motion
• C. Ask the client to bear down while inserting the catheter
• D. Inflate the catheter balloon after urine begins to flow

Correct answer: D

Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.

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