Nursing Elites

1. A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer.
• B. FACES pain scale.
• C. Auscultate the newborn's apical pulse for 60 seconds.
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.

Correct answer: C

Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.

2. For a rectal examination, the patient can be directed to assume which of the following positions?

• A. Genupectoral
• B. Sims
• C. Horizontal recumbent
• D. All of the above

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.

3. A patient requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?

• A. Diabetes mellitus
• B. Shoulder presentation
• C. Postterm with oligohydramnios
• D. Chorioamnionitis

Correct answer: C

Rationale: Postterm pregnancy with oligohydramnios is a contraindication for the use of oxytocin due to the increased risk of uterine hyperstimulation and fetal distress. Oxytocin can further stress the fetus in this scenario, potentially leading to adverse outcomes. Therefore, it is crucial for the nurse to recognize this contraindication to ensure the safety of both the mother and the baby during labor.

4. A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?

• A. Instill 500 ml of solution through the NG tube.
• B. Insert a large-bore NG tube.
• C. Use a cold irrigation solution.
• D. Instruct the client to lie on their right side.

Correct answer: B

Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.

5. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?

• A. Confront the client about this behavior.
• B. Express sympathy for the client's situation.
• C. Speak assertively to the client.
• D. Stand within 30 cm (1 ft) of the client when speaking with them.

Correct answer: A

Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.

Similar Questions