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 assessing a client with pneumonia. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased respiratory rate
• C. Decreased temperature
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Increased respiratory rate. In pneumonia, the body tries to compensate for the reduced ability to oxygenate the blood by increasing the respiratory rate. This helps to improve oxygen exchange. Bradycardia (Choice A) is not typically associated with pneumonia, as an increased heart rate is more common due to the stress on the body. Decreased temperature (Choice C) is not a typical finding in pneumonia, as infections usually cause a fever. Elevated blood pressure (Choice D) is not a common finding in pneumonia unless there are complications such as sepsis.

3. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

• A. Remove blood-saturated dressings
• B. Apply clean dressings over the saturated ones and hold pressure
• C. Elevate the wound above heart level
• D. Leave the wound open to air

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

4. A client with a closed head injury has their eyes open when pressure is applied to the nail beds, and they exhibit adduction of the arms with flexion of the elbows and wrists. The client also moans with stimulation. What is the client's Glasgow Coma Score?

• A. 4
• B. 7 (comatose)
• C. 9
• D. 10

Correct answer: B

Rationale: The client's Glasgow Coma Score is 7. This is calculated by assigning 2 points for eye-opening to pain, 2 points for incomprehensible sounds, and 3 points for flexion posturing. Choices A, C, and D are incorrect. Choice A (4) would be the score if the client displayed decerebrate posturing instead of flexion posturing. Choice C (9) would be the score if the client exhibited eye-opening to speech, confused speech, and decorticate posturing. Choice D (10) would be the score if the client showed eye-opening spontaneously, oriented speech, and obeyed commands, which is not the case here.

5. A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

• A. Contact
• B. Droplet
• C. Protective
• D. Airborne

Correct answer: D

Rationale: The correct answer is D: Airborne. Tuberculosis is spread through small droplets that remain airborne for longer periods, hence requiring airborne precautions. Choice A - Contact precautions are used for diseases spread by direct or indirect contact. Choice B - Droplet precautions are for diseases transmitted by large respiratory droplets that can travel short distances. Choice C - Protective isolation is not necessary for tuberculosis, as it is not spread through contact with the client.

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