Nursing Elites

1. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

• A. Measuring the BP after the client has sat quietly for 5 minutes
• B. Having the client sit with the arm bared and supported at heart level
• C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
• D. Measuring the BP after the client reports that he just drank a cup of coffee

Correct answer: C

Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.

2. An adult who was recently diagnosed with glaucoma tells the nurse, 'it feels like I am driving through a tunnel.' The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

• A. Maintain prescribed eye drop regimen
• B. Avoid frequent eye pressure measurements
• C. Wear prescription glasses
• D. Eat a diet high in carotene

Correct answer: A

Rationale: The correct answer is A: Maintain prescribed eye drop regimen. In glaucoma, maintaining the prescribed eye drop regimen is crucial for controlling intraocular pressure, which helps in preventing vision loss. Consistent use of eye drops as directed can slow down the progression of the disease and preserve vision. Choice B is incorrect because avoiding frequent eye pressure measurements does not address the primary treatment for glaucoma. Choice C is incorrect as wearing prescription glasses may be helpful for vision correction but does not directly address the management of glaucoma. Choice D is incorrect because while a diet high in carotene may promote overall eye health, it is not the most important instruction for managing glaucoma.

3. A client has lost a significant amount of blood due to complications during surgery. What parameter does the nurse recognize as the earliest indication of new decreases in fluid volume?

• A. Pulse rate
• B. Blood pressure
• C. Pulmonary artery systolic pressure
• D. Pulmonary artery end-diastolic pressure

Correct answer: A

Rationale: The earliest indication of new decreases in fluid volume is often recognized by an increase in pulse rate. Cardiac output is influenced by circulating blood volume, heart pumping action, and vascular tone. As fluid volume decreases, the body compensates by increasing the pulse rate. The formula for cardiac output is pulse rate multiplied by stroke volume. An elevated pulse rate helps maintain blood pressure with minor volume depletion. Pulmonary artery systolic pressure and pulmonary artery end-diastolic pressure, obtained through a pulmonary artery catheter, provide insights into pulmonary artery and left ventricle pressures at the end of diastole. These parameters are not the earliest indicators of new decreases in fluid volume compared to pulse rate.

4. The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy?

• A. The biopsy will confirm the diagnosis of Hodgkin's disease.
• B. The biopsy will show the extent of the disease in the bones.
• C. The biopsy will be done to check for infection in the bones.
• D. The biopsy will help determine the best treatment for the disease.

Correct answer: D

Rationale: A bone marrow biopsy helps determine the best treatment plan for Hodgkin's disease by providing crucial information about the extent and nature of the disease. While confirming the diagnosis is important, the primary purpose of the biopsy in this case is to guide treatment decisions. The biopsy is not primarily for assessing the extent of the disease in the bones or checking for infections in the bones.

5. A young adult client, admitted to the Emergency Department following a motor vehicle collision, is transfused with 4 units of PRBCs (packed red blood cells). The client's pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all the PRBCs have been transfused?

• A. 0.19
• B. 0.09
• C. 0.39
• D. 0.29

Correct answer: D

Rationale: The expected increase in hematocrit after transfusion is approximately 3% per unit of PRBCs. Since the client received 4 units, the expected increase would be 4 x 3% = 12%. Therefore, adding this to the pretransfusion hematocrit of 17% would result in an expected post-transfusion hematocrit of 29%. Choice A (0.19) is incorrect as it doesn't consider the incremental increase per unit of PRBCs. Choices B (0.09) and C (0.39) are also incorrect as they do not align with the expected increase in hematocrit following the transfusion of 4 units of PRBCs.

Similar Questions