Nursing Elites

1. A nurse is assessing a client for signs of anemia. Which of the following findings should the nurse look for?

• A. Increased energy
• B. Pale skin
• C. Elevated blood pressure
• D. Weight gain

Correct answer: B

Rationale: The correct answer is B: 'Pale skin.' Pale skin is a common sign of anemia due to reduced hemoglobin levels, which affects the skin color. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin in the blood, leading to a paler complexion. Choices A, C, and D are incorrect. 'Increased energy' is not typically associated with anemia, as fatigue is a common symptom. 'Elevated blood pressure' is not a typical finding in anemia; instead, anemia may cause hypotension. 'Weight gain' is not a direct symptom of anemia; in fact, weight loss may occur in some cases due to reduced appetite or other factors associated with anemia.

2. What can cause a low pulse oximetry reading?

• A. Hyperthermia
• B. Increased hemoglobin level
• C. Inadequate peripheral circulation
• D. Low altitudes

Correct answer: C

Rationale: Inadequate peripheral circulation can cause a low pulse oximetry reading by limiting blood flow to the area being measured, leading to inaccurate oxygen saturation readings. Hyperthermia (choice A) is an elevated body temperature and does not directly affect pulse oximetry readings. An increased hemoglobin level (choice B) would actually lead to higher oxygen-carrying capacity in the blood, resulting in normal or increased pulse oximetry readings. Low altitudes (choice D) typically do not cause low pulse oximetry readings unless there are other underlying conditions affecting oxygen levels.

3. What is an example of a culturally sensitive response from a healthcare provider when a patient mentions feeling uncomfortable with a treatment plan?

• A. Asking why they feel this way
• B. Explaining that the treatment is standard
• C. Inviting the patient to share concerns
• D. Offering alternative treatments

Correct answer: C

Rationale: Inviting the patient to share concerns is an example of a culturally sensitive response as it acknowledges the patient's feelings and provides a safe space for them to express their discomfort. This approach shows respect for the patient's cultural beliefs and values by valuing their perspective. Choice A, asking why they feel this way, can be perceived as confrontational and may not encourage open communication. Choice B, explaining that the treatment is standard, dismisses the patient's feelings and does not address their discomfort. Choice D, offering alternative treatments, may be premature without fully understanding the patient's concerns first.

4. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

• A. Provide an orthodontic pacifier for comfort
• B. Offer fluids using a straw
• C. Cleanse the suture line with a cotton-tip swab
• D. Remove elbow splints periodically to perform range of motion

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

5. A client gave birth 4 hours ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?

• A. Elevate the client's legs to a 30° angle
• B. Insert an indwelling urinary catheter
• C. Massage the client's fundus
• D. Initiate an infusion of oxytocin

Correct answer: C

Rationale: The correct answer is to massage the client's fundus first. Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus can help stimulate uterine contractions, which will assist in reducing bleeding. Elevating the client's legs to a 30° angle (Choice A) is not the priority in this situation as fundal massage takes precedence. Inserting an indwelling urinary catheter (Choice B) may be necessary but should not take precedence over managing the postpartum hemorrhage. Initiating an infusion of oxytocin (Choice D) is a valid intervention to address uterine atony, but massaging the fundus should come first to promote immediate contraction and control bleeding.

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