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. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?

• A. Securely grasp the client's arm and leg.
• B. Put bed rails up on the side of bed opposite from the nurse.
• C. Correctly position and use a turn sheet.
• D. Lower the head of the client's bed slowly

Correct answer: B

Rationale: When turning an immobile bedridden client without assistance, the best action to ensure client safety is to put bed rails up on the side of the bed opposite from the nurse. This is important because the nurse can only stand on one side of the bed, so having bed rails on the opposite side prevents the client from falling out of bed. Option A, which suggests securely grasping the client's arm and leg, can potentially cause client injury to the skin or joints. Options C and D, correctly positioning and using a turn sheet, and lowering the head of the client's bed slowly, respectively, are useful techniques during client turning but are of lower priority in terms of safety compared to the use of bed rails.

3. The nurse is reviewing percussion techniques with a new graduate nurse. Which action performed by the graduate nurse while percussing requires the nurse to intervene?

• A. Percussing twice over each area
• B. Striking with the fingertip, not the finger pad
• C. Using the wrist to make the strikes, not the arm
• D. Quickly lifting the striking finger after each stroke

Correct answer: A

Rationale: The correct answer is to percuss twice over each area, not once. This technique helps ensure a more accurate assessment. Striking with the fingertip instead of the finger pad is correct because the tip of the finger produces clearer sounds. Using the wrist to make the strikes instead of the arm is appropriate as it allows for more controlled and precise percussion. Quickly lifting the striking finger after each stroke is also correct to prevent damping off vibrations. Therefore, percussing once over each area (Choice A) is incorrect as it does not follow the standard percussion technique.

4. Which of these specific measurements is the best index of a child's general health?

• A. Body mass index
• B. Height and weight
• C. Head circumference
• D. Chest circumference

Correct answer: B

Rationale: Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.

5. You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?

• A. The water
• B. Help to the bathroom
• C. The chest pain
• D. The crying person

Correct answer: D

Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.

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