Nursing Elites

1. A nurse is reviewing the laboratory results of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin 12 g/dL
• B. Glucose 50 mg/dL
• C. Bilirubin 4 mg/dL
• D. Platelets 200,000/mm³

Correct answer: C

Rationale: The correct answer is C: Bilirubin 4 mg/dL. A bilirubin level of 4 mg/dL is elevated for a newborn and requires monitoring and potential intervention to prevent complications such as jaundice and kernicterus. Elevated bilirubin levels in newborns can lead to serious neurological consequences. Choices A, B, and D are within normal ranges for a newborn and do not require immediate reporting to the provider. Therefore, the nurse should prioritize reporting the elevated bilirubin level to the provider for further evaluation and management.

2. Before administering blood products, which action should be taken?

• A. Assess the patient's temperature
• B. Document the patient’s response
• C. Prime IV tubing with 0.45% sodium chloride
• D. Administer epinephrine

Correct answer: A

Rationale: Before administering blood products, assessing the patient’s temperature is crucial. This action provides baseline data to detect any febrile reactions during or after the transfusion. Fever may indicate a transfusion reaction, so continuous monitoring of vital signs is essential throughout the procedure. Documenting the patient’s response (choice B) is important but comes after assessing the temperature. Priming IV tubing with 0.45% sodium chloride (choice C) is not directly related to the initial action required before administering blood products. Administering epinephrine (choice D) is not indicated unless there is a severe allergic reaction, which is not the standard initial step before blood product administration.

3. A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?

• A. Increased blood pressure
• B. Pulse deficit
• C. Normal heart rate
• D. Elevated oxygen saturation

Correct answer: B

Rationale: The correct answer is B: Pulse deficit. A pulse deficit is a significant finding in clients with dysrhythmias, indicating ineffective cardiac contractions. Pulse deficit occurs when there is a difference between the apical and radial pulses, suggesting that not all heart contractions are strong enough to produce a pulse that can be felt peripherally. Increased blood pressure (choice A) may occur due to various factors and is not a direct indicator of ineffective cardiac contractions. Similarly, a normal heart rate (choice C) and elevated oxygen saturation (choice D) do not specifically point towards ineffective cardiac contractions; they can be present in individuals with dysrhythmias but do not directly indicate ineffective cardiac contractions.

4. A client in labor has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?

• A. Polyuria
• B. Hypertension
• C. Pruritus
• D. Dry mouth

Correct answer: C

Rationale: Pruritus is a common adverse effect of epidural anesthesia, often due to the opioids administered with the epidural. It presents as itching on the skin and can cause significant discomfort to the client. Polyuria (excessive urination) and dry mouth are not typical adverse effects of epidural anesthesia. Hypertension is not commonly associated with epidural anesthesia; in fact, hypotension is a more frequent complication due to sympathetic blockade. Therefore, the correct answer is pruritus (choice C), as it is a known adverse effect of epidural anesthesia.

5. A healthcare provider is preparing to administer a vaccine to a child. Which of the following should the provider verify?

• A. Allergy to eggs
• B. Previous vaccination history
• C. Family medical history
• D. Growth charts

Correct answer: B

Rationale: The healthcare provider should verify the child's previous vaccination history to ensure they are up to date with immunizations. This is important to prevent unnecessary or duplicate vaccinations and ensure the child is adequately protected against vaccine-preventable diseases. Checking for allergies to eggs is relevant for certain vaccines like the influenza vaccine but is not the top priority in this scenario. Family medical history and growth charts are not directly related to the administration of vaccines and are not as crucial as confirming the child's vaccination status.

Similar Questions