Nursing Elites

1. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

2. Which of the following is a negative outcome associated with impaired mobility?

• A. Increased amounts of calcium are absorbed from circulation
• B. A drop in blood pressure occurs when rising from a sitting to a standing position
• C. The amount of mucus in the bronchi and lungs decreases
• D. The vessel walls of the circulatory system thicken

Correct answer: B

Rationale: A client with impaired mobility may develop changes in body systems that put them at risk of further illness or injury. One negative outcome associated with impaired mobility is orthostatic hypotension, where blood pressure drops significantly when moving from a sitting or lying position to a standing position. This drop in blood pressure can lead to symptoms such as dizziness or fainting. This occurs because blood circulates more slowly or pools in the distal extremities due to impaired mobility. Choice A is incorrect because increased calcium absorption is not a typical negative outcome associated with impaired mobility. Choice C is incorrect because a decrease in mucus in the bronchi and lungs is not a common negative outcome of impaired mobility. Choice D is incorrect because thickening of vessel walls in the circulatory system is not directly associated with impaired mobility.

3. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?

• A. The popliteal artery should be auscultated to obtain thigh pressure.
• B. The best position to measure thigh pressure is the prone position.
• C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
• D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.

Correct answer: C

Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.

4. Which of these guidelines would a healthcare professional follow when measuring a patient's weight?

• A. The patient is always weighed wearing only undergarments.
• B. The type of scale matters and should be consistent day to day.
• C. The patient should remove heavy outer clothing, shoes, and jackets before weighing.
• D. Attempts should be made to weigh the patient at approximately the same time of day if a sequence of weights is necessary.

Correct answer: D

Rationale: When measuring a patient's weight, it is important to ensure accuracy and consistency. If a sequence of repeated weights is necessary, the healthcare professional should attempt to weigh the patient at the same time of day and with the same types of clothing worn each time. It is crucial to use a standardized balance or electronic standing scale for accurate weight measurement. Choice A is incorrect as patients should remove heavy outer clothing, shoes, and jackets before being weighed for accurate results. Choice B is incorrect because the type of scale used does matter and should be consistent for reliable weight tracking. Choice C is incorrect as patients should not leave on heavy outer clothing, shoes, or jackets as these items can add to the weight recorded inaccurately.

5. When are manual hematocrits done?

• A. to monitor anemia
• B. by using a microhematocrit tube.
• C. to measure the percentage of plasma to cells.
• D. All of the above.

Correct answer: D

Rationale: Manual hematocrits are performed to monitor anemia, which involves measuring the percentage of red blood cells in the blood. The process involves collecting blood in a microhematocrit tube, then centrifuging it to separate the plasma from the cells. By measuring the ratio of plasma to cells, healthcare providers can assess the patient's hematocrit level. Therefore, all the provided options are correct as they collectively describe the purpose and procedure of manual hematocrits.

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