Nursing Elites

1. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

• A. Notify the manufacturer
• B. Disconnect the machine, and measure the blood pressure manually every 15 min
• C. Adjust the machine settings again
• D. Ignore the extra readings

Correct answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

2. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?

• A. Examine the elbow
• B. Administer pain medication
• C. Apply a warm compress to the elbow
• D. Assess the client’s range of motion

Correct answer: A

Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.

3. A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

• A. 100 mL/hr
• B. 150 mL/hr
• C. 75 mL/hr
• D. 50 mL/hr

Correct answer: A

Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.

4. When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?

• A. Offer the client tart or sour foods.
• B. Ensure the client is sitting upright while eating.
• C. Provide soft and easily swallowable foods.
• D. Give the client thickened liquids to help with swallowing.

Correct answer: B

Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.

5. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Decrease in heart rate
• B. Fluid volume deficit causes tachycardia
• C. Decrease in blood pressure
• D. Increase in respiratory rate

Correct answer: A

Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.

Similar Questions