Nursing Elites

1. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

• A. Notify the pediatrician immediately.
• B. Teach the parents about congenital heart defects.
• C. Document the finding in the infant's record.
• D. Apply oxygen via nasal cannula at 3 L/min.

Correct answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

2. Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

• A. Cold sensitivity.
• B. Hot flashes.
• C. Weight gain.
• D. Dry skin.

Correct answer: A

Rationale: The correct answer is A: Cold sensitivity. Cold sensitivity is a common symptom of hypothyroidism, a condition that affects the thyroid gland's ability to produce enough hormones. As a postmenopausal woman presents with cold sensitivity, it may indicate an underlying thyroid issue. Hot flashes (choice B) are more commonly associated with menopause than thyroid dysfunction. While weight gain (choice C) and dry skin (choice D) can also be symptoms of thyroid disorders, cold sensitivity is more specific and indicative of hypothyroidism, requiring prompt evaluation by a healthcare provider.

3. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?

• A. Serum potassium level
• B. Hemoglobin level
• C. White blood cell count
• D. Serum calcium level

Correct answer: A

Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.

4. When a client with a history of atrial fibrillation is admitted with a new onset of confusion, which diagnostic test should the nurse anticipate preparing the client for first?

• A. Electrocardiogram (ECG)
• B. Chest X-ray
• C. Arterial blood gases (ABGs)
• D. Echocardiogram

Correct answer: A

Rationale: The correct answer is an Electrocardiogram (ECG). When a client with a history of atrial fibrillation presents with new-onset confusion, an ECG is crucial to assess for cardiac ischemia, which could be a potential cause of the confusion. A chest X-ray (Choice B) is not typically the first-line diagnostic test for evaluating confusion in a client with atrial fibrillation. Arterial blood gases (ABGs) (Choice C) are more useful in assessing oxygenation and acid-base balance rather than the cause of confusion in this scenario. While an echocardiogram (Choice D) provides valuable information about cardiac structure and function, it is usually not the initial diagnostic test needed in the evaluation of acute confusion in a client with atrial fibrillation.

5. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

• A. Encourage the patient to stay at the bedside
• B. Use distraction techniques to reduce pain
• C. Maintain strict aseptic technique
• D. Place a drape over the burn area

Correct answer: C

Rationale: Maintaining strict aseptic technique is crucial before a dressing change for burn patients to prevent infection. Encouraging the patient to stay at the bedside, using distraction techniques, or placing a drape over the burn area are not as critical as ensuring asepsis in this situation.

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