Nursing Elites

1. Patients exhibiting signs of cyanosis will:

• A. show signs of hyperoxia.
• B. have increased O2 saturation.
• C. have blood levels of CO2 higher than O2 levels.
• D. None of the above.

Correct answer: C

Rationale: Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from low blood oxygen levels. When a patient exhibits cyanosis, it indicates that their blood is poorly oxygenated, leading to a higher concentration of CO2 compared to oxygen. Options A and B are incorrect as cyanosis is associated with low oxygen levels, not hyperoxia or increased O2 saturation. Therefore, the correct answer is that patients exhibiting cyanosis will have blood levels of CO2 higher than O2 levels.

2. The Rule of Nines is used to:

• A. determine the amount of the body surface that has been burned
• B. assess the level of oxygen saturation in a body that has been burned.
• C. determine the level of tissue damage that has occurred in a burn.
• D. None of the above.

Correct answer: A

Rationale: The Rule of Nines is used to assess the amount of body surface that has been burned. Most body areas are divided out based on 9%, with the exception of the genitalia, which is only 1%.

3. The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?

• A. Yield a falsely low blood pressure
• B. Yield a falsely high blood pressure
• C. Be the same, regardless of cuff size
• D. Vary as a result of the technique of the person performing the assessment

Correct answer: B

Rationale: Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.

4. What action by the nurse is appropriate when examining a 16-year-old male teenager?

• A. Discuss health teaching with the teenager to promote wellness.
• B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
• C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
• D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.

Correct answer: D

Rationale: During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.

5. You are ready to give your resident a complete bed bath. The temperature of this bath water should be which of the following?

• A. Cooler than a tub bath.
• B. Hotter than a tub bath.
• C. About 106 degrees.
• D. Over 120 degrees.

Correct answer: C

Rationale: The correct temperature for a bed bath water should be about 106 degrees. This temperature is considered safe and comfortable for residents. Using a bath thermometer is essential to ensure the water is not too hot, as hot water can cause burns. On the other hand, water that is too cool can lead to discomfort, shivering, and chilling. Options A, B, and D are incorrect because cooler water may cause discomfort and shivering, hotter water can lead to burns, and water over 120 degrees is considered too hot and risky for a resident's skin.

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