Nursing Elites

1. Each small square on the EKG paper is:

• A. 0.04 seconds long and 5mm tall
• B. 0.2 seconds long and 5mm tall
• C. 0.04 seconds long and 20mm tall
• D. 0.04 seconds long and 1mm tall

Correct answer: D

Rationale: Each small square on an EKG paper represents 0.04 seconds long and 1mm tall. This standardization is essential for accurate measurements. One large square on EKG paper consists of 5 small squares in length and 5 small squares in height, which equals 0.2 seconds long and 5mm tall (0.5 mV). Choice A is incorrect because while the duration is correct, the height mentioned is not accurate. Choice B is incorrect as it provides the correct height but the duration is inaccurate. Choice C is incorrect as the height mentioned is exaggerated, and the duration is correct but the height is not. Therefore, the correct answer is 0.04 seconds long and 1mm tall.

2. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

• A. The nurse ties the restraints in a square knot to prevent the client from untying them
• B. The restraints are attached to a movable portion of the bed
• C. The padded side of the restraint is applied next to the skin of the wrist
• D. The nurse assesses the client's distal circulation every 24 hours

Correct answer: C

Rationale: Restraint use must prioritize the safety of the client. When applying restraints around the wrists, the padded side should be placed against the skin to help prevent skin breakdown. Additionally, restraints should be secured in quick-release knots to ensure they can be removed rapidly in case of an emergency. Choice A is incorrect as restraints should not be tied in a way that could prevent quick removal. Choice B is incorrect because restraints should not be attached to a movable part of the bed to avoid unintentional movement. Choice D is incorrect as assessing distal circulation is important but is not directly related to the safe application of restraints.

3. When would chest thrusts be performed in an emergency situation?

• A. When performing CPR to initiate cardiovascular circulation.
• B. When assessing responsiveness of an unconscious patient.
• C. When assisting a pregnant woman who is choking.
• D. None of the above examples indicate the need for chest thrusts.

Correct answer: C

Rationale: In the scenario of an emergency where a pregnant woman is choking, chest thrusts are performed to clear the airway obstruction. This technique is used instead of abdominal thrusts to avoid potential harm to the fetus. While chest thrusts are not as effective as abdominal thrusts in clearing obstructions, they are the preferred method in this specific situation. Choices A and B are incorrect as chest thrusts are not typically performed during CPR to initiate cardiovascular circulation or when assessing responsiveness of an unconscious patient. Choice D is incorrect as chest thrusts are indeed warranted when assisting a pregnant woman who is choking.

4. A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?

• A. Anorexia
• B. Aspiration
• C. Self-care deficit
• D. Inadequate intake

Correct answer: B

Rationale: When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.

5. The nurse is assessing an 80-year-old male patient. Which assessment finding would be considered normal?

• A. Decrease in body weight from his younger years
• B. Decrease in deposits of fat in the cheeks and forearms
• C. Presence of kyphosis and flexion in bilateral knees and hips
• D. Change in overall body proportion, including a longer trunk and shorter extremities

Correct answer: C

Rationale: In an 80-year-old male patient, the presence of kyphosis (rounded upper back) and flexion in bilateral knees and hips are considered normal age-related changes. These postural changes are commonly seen in older adults due to structural changes in the spine and joints. Option A is incorrect as aging individuals typically experience a decrease in body weight, not an increase. Option B is also incorrect as there is usually a decrease in subcutaneous fat from the face and periphery, rather than an increase in fat deposits in specific areas. Option D is incorrect because the change in overall body proportion with aging usually involves a shorter trunk and relatively longer extremities, not the other way around. This is because long bones do not shorten with age, leading to this characteristic change in body proportions.

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