Nursing Elites

1. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?

• A. This too shall pass.
• B. Take the child immediately to the ER
• C. Contact the Poison Control Center quickly
• D. Give the child syrup of ipecac

Correct answer: C

Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.

2. Why should a palpated pressure be performed before auscultating blood pressure?

• A. To more clearly hear the Korotkoff sounds.
• B. To detect the presence of an auscultatory gap.
• C. To avoid missing a falsely elevated blood pressure.
• D. To more readily identify phase IV of the Korotkoff sounds.

Correct answer: B

Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.

3. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

• A. "I can always trust my family."?
• B. "It seems like I always have bad luck."?
• C. "You never know who will turn against you."?
• D. "I hear evil voices that tell me to do bad things."?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

4. Which of the following safety precautions should the nurse discuss when working with an immunocompromised client?

• A. Avoid canned foods and increase consumption of fresh fruits and vegetables
• B. Hand-wash utensils after use and allow them to air dry
• C. Only drink tap water that has been filtered or boiled before consumption
• D. Never eat meals prepared in restaurants

Correct answer: C

Rationale: The correct answer is to only drink tap water that has been filtered or boiled before consumption. Immunocompromised clients are susceptible to infections, so it is essential to take precautions to prevent exposure to harmful pathogens. Drinking tap water that has been filtered or boiled helps eliminate potential pathogens that could be harmful to the client's health. Choices A, B, and D do not directly address the issue of avoiding potential pathogens that could compromise the health of an immunocompromised client. Thus, they are incorrect. Hand-washing utensils, avoiding canned foods, and increasing fruit and vegetable consumption are good general hygiene practices but may not specifically address the needs of an immunocompromised client.

5. One of your patients is dependent on a mechanical ventilator for their respiratory needs. The patient cannot breathe on their own. Suddenly, the lights in the patient's room and the entire nursing unit go off. You realize that the electric power has been lost. What is the first thing that you should do for this patient?

• A. Plug the ventilator into the red outlet in the room.
• B. Plug the ventilator into the blue outlet in the room.
• C. Use an Ambu bag to ventilate the patient.
• D. Call the doctor about this emergency.

Correct answer: B

Rationale: In healthcare facilities, emergency generators are in place in case of power outages. The red outlets in patient rooms are connected to the emergency generator and provide power during such situations. By plugging the ventilator into the red outlet, you ensure that the patient's mechanical ventilation needs are met despite the power loss. Using an Ambu bag or calling the doctor should be secondary actions after ensuring the ventilator is powered correctly. Plugging the ventilator into the blue outlet is incorrect and can result in the ventilator not functioning during a power outage.

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