Nursing Elites

1. The nurse is calculating the one-minute Apgar score for a newborn male infant and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant?

• A. 8
• B. 9
• C. 6
• D. 7

Correct answer: A

Rationale: The correct answer is A: 8. The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a good heart rate, vigorous cry, good muscle tone, and quick reflex irritability, which would total to 8. The only factor affecting the score is the cyanotic color, which could indicate potential respiratory or circulatory issues. Choices B, C, and D are incorrect as they do not reflect the overall assessment provided in the scenario.

2. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?

• A. Did you try to resist or fight back when you felt uncomfortable?
• B. He hurt you? Can you elaborate on what happened?
• C. It is okay to cry, but first, let's address your injuries and the situation.
• D. Yes, I can see. Tell me more about what you remember.

Correct answer: D

Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.

3. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

• A. Determine if the urinary bladder is distended
• B. Irrigate the indwelling urinary catheter
• C. Review the temperature graph for the last day
• D. Administer an antihypertensive agent

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

4. A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)

• A. 2
• B. 3
• C. 4
• D. 5

Correct answer: A

Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

5. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?

• A. Monitor the client’s cardiac activity via telemetry.
• B. Maintain venous access with an infusion of normal saline.
• C. Assess glucose levels via finger stick every 4 to 6 hours.
• D. Evaluate hourly urine output for the return of normal renal function.

Correct answer: A

Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client’s cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.

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