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. After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?

• A. Lethargy
• B. Increased pulse rate and blood pressure
• C. Muscle weakness
• D. Muscle irritability

Correct answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.

3. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:

• A. A ham and Swiss cheese sandwich on whole wheat bread
• B. Mashed potatoes and broiled chicken
• C. A tossed salad with oil and vinegar and olives
• D. Chicken bouillon

Correct answer: B

Rationale: The correct answer is B: Mashed potatoes and broiled chicken. Both mashed potatoes and broiled chicken are typically low in sodium content, making them suitable choices for a 500-mg low sodium diet. The other options, such as a ham and Swiss cheese sandwich on whole wheat bread, a tossed salad with oil and vinegar and olives, and chicken bouillon, may contain higher amounts of sodium and are not typically recommended for a low sodium diet.

5. Which of the following conditions may necessitate fluid restriction?

• A. Fever
• B. Chronic Obstructive Pulmonary Disease
• C. Renal Failure
• D. Dehydration

Correct answer: C

Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.

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