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 is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

• A. Take the medication with milk
• B. Take with a glass of orange juice
• C. Take at bedtime
• D. Take with meals

Correct answer: B

Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.

3. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?

• A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
• B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
• C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
• D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.

Correct answer: B

Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.

4. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?

• A. I should reduce my fluid intake to 2 hours before bedtime
• B. I will watch TV in bed before sleeping
• C. I can take long naps during the day
• D. I should exercise right before going to bed

Correct answer: A

Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.

5. A client has been prescribed vasopressin for the treatment of diabetes insipidus. What is the expected pharmacological action of this medication?

• A. To stimulate the pancreas to secrete insulin
• B. To slow the absorption of glucose in the intestine
• C. To increase reabsorption of water in the renal tubules
• D. To increase blood pressure

Correct answer: C

Rationale: The correct answer is C: To increase reabsorption of water in the renal tubules. Vasopressin mimics the action of antidiuretic hormone (ADH) by increasing the reabsorption of water in the renal tubules. This leads to decreased urine output, helping to manage symptoms of diabetes insipidus, which is characterized by excessive thirst and urination. Choices A, B, and D are incorrect. Vasopressin does not stimulate the pancreas to secrete insulin, slow the absorption of glucose in the intestine, or directly increase blood pressure.

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