Nursing Elites

1. A nurse is planning to delegate to an AP the task of fasting blood glucose testing for a client who has diabetes mellitus. Which of the following actions should the nurse take?

• A. Determine if the AP is qualified to perform the test
• B. Help the AP perform the blood glucose test
• C. Assign the AP to ask the client if they have taken diabetic medication today
• D. Have the AP check the medical record for prior blood glucose test results

Correct answer: A

Rationale: Before delegating any task, the nurse must determine whether the AP is qualified to perform it. In this scenario, verifying the AP's competency to conduct fasting blood glucose testing is crucial for patient safety and compliance with facility protocols. The other choices are incorrect because they do not address the essential step of assessing the AP's ability to perform the delegated task. While helping the AP or assigning tasks related to diabetic medication or medical records are important, the primary concern should be confirming the AP's competence for the specific delegated duty of blood glucose testing.

2. A client presents with symptoms suggestive of rheumatoid arthritis. Which of the following laboratory tests should be ordered to confirm this diagnosis?

• A. Erythrocyte sedimentation rate (ESR)
• B. Rheumatoid factor
• C. Antinuclear antibody
• D. Serum calcium

Correct answer: B

Rationale: Rheumatoid factor is a specific marker for rheumatoid arthritis. It is often elevated in clients with this autoimmune condition, helping to confirm the diagnosis. Erythrocyte sedimentation rate (ESR) and antinuclear antibody tests can be supportive but are not specific for rheumatoid arthritis. Serum calcium levels are not typically used to confirm this diagnosis.

3. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

• A. Vernix caseosa
• B. Head circumference of 34 cm
• C. Jaundice at 24 hours of age
• D. Respiratory rate of 50/min

Correct answer: C

Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.

4. A healthcare provider is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the healthcare provider plan to administer?

• A. Lidocaine
• B. Adenosine
• C. Atropine
• D. Verapamil

Correct answer: C

Rationale: The client presents with bradycardia, diaphoresis, and chest pain, indicating reduced cardiac output. Atropine is the appropriate choice as it increases heart rate by blocking the parasympathetic nervous system. Lidocaine is used for ventricular arrhythmias, Adenosine for supraventricular tachycardia, and Verapamil for controlling heart rate in atrial fibrillation or atrial flutter. These medications are not suitable for the client's current presentation.

5. A client who is 8 hours postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborn’s blood type is B positive. Which of the following statements is appropriate?

• A. You only need to receive Rh immune globulin if you have a positive blood type.
• B. You should receive Rh immune globulin within 72 hours of delivery.
• C. Both you and your baby should receive Rh immune globulin at your 6-week appointment.
• D. Immune globulin is not necessary since this is your second pregnancy.

Correct answer: B

Rationale: The correct answer is B. Rh-negative mothers who give birth to an Rh-positive baby should receive Rh immune globulin within 72 hours of delivery to prevent the development of antibodies in future pregnancies. Choice A is incorrect because Rh-negative individuals are the ones who require Rh immune globulin. Choice C is incorrect as the administration of Rh immune globulin is time-sensitive and not typically scheduled for a 6-week appointment. Choice D is incorrect because Rh immune globulin is necessary to prevent sensitization regardless of the number of pregnancies.

Similar Questions