A newborn infant is evaluated using the Apgar scoring system. The infant has a heart rate of 120 beats per minute, flexion of the extremities, cries vigorously, pulls away from suctioning, and is acrocyanotic. What is the Apgar score for this newborn?

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Question 1 of 5

A newborn infant is evaluated using the Apgar scoring system. The infant has a heart rate of 120 beats per minute, flexion of the extremities, cries vigorously, pulls away from suctioning, and is acrocyanotic. What is the Apgar score for this newborn?

Correct Answer: C

Rationale: HR >100 = 2, cries = 2, flexion = 2, pulls away = 2, acrocyanosis = 1; total = 9.

Question 2 of 5

A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?

Correct Answer: B

Rationale: Current evidence shows saline instillation before suctioning is not recommended as it may dislodge bacteria or cause irritation.

Question 3 of 5

The nurse knows that anemia will result in

Correct Answer: A

Rationale: The correct answer is A: Hypoxemia. Anemia results in decreased red blood cells, leading to reduced oxygen-carrying capacity in the blood. This causes hypoxemia, a condition where there is a low level of oxygen in the blood. Hypoglycemia (B) is low blood sugar, not related to anemia. Impaired ventilation (C) refers to breathing difficulties, not directly caused by anemia. Hypovolemia (D) is a decrease in blood volume, which can result from acute blood loss but is not specific to anemia.

Question 4 of 5

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?

Correct Answer: A

Rationale: The correct answer is A: Assist patient to cough, turn, and deep breathe every 2 hours. This intervention helps prevent hospital-acquired pneumonia by promoting lung expansion, preventing atelectasis, and improving air exchange. Turning the patient reduces pressure ulcers. Coughing helps clear secretions, reducing the risk of pneumonia. Deep breathing strengthens respiratory muscles. Encouraging frequent movement and deep breathing prevents pooling of secretions in the lungs, which can lead to infection. Choices B, C, and D do not directly address promoting lung expansion and clearing secretions to prevent pneumonia.

Question 5 of 5

A nurse is providing discharge instructions for a client prescribed a new inhaled corticosteroid. Which of the following should the nurse emphasize?

Correct Answer: B

Rationale: The correct answer is B: Rinse your mouth after using the inhaler. This is important because inhaled corticosteroids can increase the risk of oral thrush, so rinsing the mouth helps prevent this side effect. Choice A is incorrect because inhaled corticosteroids are not used during acute asthma attacks. Choice C is incorrect because inhaled corticosteroids are typically taken on an empty stomach. Choice D is incorrect because using a spacer with the inhaler can actually improve medication delivery and effectiveness.

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