Nursing Elites

1. Why is a pulse oximeter attached to Mr. Dizon's finger?

• A. To determine if the patient's hemoglobin level is low and if he requires a blood transfusion
• B. To check the level of the patient's tissue perfusion
• C. To measure the effectiveness of the patient's anti-hypertensive medications
• D. To detect oxygen saturation of arterial blood before symptoms of hypoxemia develop

Correct answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

2. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

3. A nurse is teaching a client about complete and incomplete proteins. Which of the following foods should the nurse include in the teaching as an incomplete protein?

• A. 4 oz chickpeas
• B. 2 poached eggs
• C. 2 oz cheddar cheese
• D. 4 oz salmon fillet

Correct answer: A

Rationale: The correct answer is A: 4 oz chickpeas. Chickpeas are considered an incomplete protein because they lack one or more essential amino acids required by the body. Incomplete proteins do not provide all essential amino acids in sufficient quantities. Choice B, 2 poached eggs, is a complete protein source because eggs contain all essential amino acids. Choice C, 2 oz cheddar cheese, is also a complete protein as it contains all essential amino acids. Choice D, 4 oz salmon fillet, is another complete protein source as fish typically provide all essential amino acids needed by the body.

4. What instruction should a nurse include when teaching a client who has recently been prescribed a low-sodium diet?

• A. Avoid foods such as smoked meats and frozen dinners.
• B. Select foods with less than 4g of sodium as indicated on food labels.
• C. Use soy sauce for flavoring foods instead of table salt.
• D. Processed and prepared foods are typically low in sodium.

Correct answer: A

Rationale: The correct answer is A, which directs the client to avoid foods such as smoked meats and frozen dinners. These types of foods are typically high in sodium, making them unsuitable for a low-sodium diet. Option B is incorrect because foods with less than 4g of sodium might still be high in sodium for individuals on low-sodium diets. The daily recommended intake of sodium for a low-sodium diet is usually around 1.5g to 2g. Hence, 4g of sodium in a single food product can be excessive. Option C is incorrect as soy sauce, although a different source of flavor, is also high in sodium and should be used sparingly, if at all, in a low-sodium diet. Option D is incorrect because processed and prepared foods are usually not low in sodium. In fact, these foods often have high sodium content due to added salts and preservatives.

5. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

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