Nursing Elites

1. A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

• A. Albumin
• B. Calcium
• C. Sodium
• D. Potassium

Correct answer: A

Rationale: The correct answer is Albumin. Albumin is a protein made by the liver and is a key indicator of the body's protein status. Low levels of albumin can indicate inadequate protein intake or synthesis. Choices B, C, and D (Calcium, Sodium, and Potassium) are not direct indicators of protein uptake and synthesis. Calcium is related to bone health, Sodium to fluid balance, and Potassium to nerve and muscle function.

2. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

3. Which physiologic effect should the nurse expect in a client addicted to hallucinogens?

• A. Dilated pupils
• B. Constricted pupils
• C. Bradycardia
• D. Bradypnea

Correct answer: B

Rationale: Clients addicted to hallucinogens often exhibit constricted pupils due to the effects of the drug on the sympathetic nervous system. This sympathetic stimulation causes the pupils to constrict rather than dilate. Choices A, C, and D are incorrect. Dilated pupils are more commonly associated with stimulant use, while bradycardia (slow heart rate) and bradypnea (slow breathing) are not typical effects of hallucinogens.

4. If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?

• A. The child and any siblings will reside in a secure environment
• B. The family will feel at ease in their relationship with the counselor
• C. The family will gain insight into their abusive behavior patterns
• D. The mother will learn to apply verbal discipline with her children

Correct answer: A

Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.

5. The nurse understands that one of these factors contributes to constipation:

• A. excessive exercise
• B. high fiber diet
• C. no regular time for defecation daily
• D. prolonged use of laxatives

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

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